Healthcare Provider Details

I. General information

NPI: 1932334133
Provider Name (Legal Business Name): MEDICAL NUTRITION THERAPY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 RAYMOND RD
AVON CT
06001-3629
US

IV. Provider business mailing address

6 RAYMOND RD
AVON CT
06001-3629
US

V. Phone/Fax

Practice location:
  • Phone: 860-677-4429
  • Fax: 860-677-4429
Mailing address:
  • Phone: 860-677-4429
  • Fax: 860-677-4429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number0003927994
License Number StateCT

VIII. Authorized Official

Name: SHARON LESLEY WERNER
Title or Position: REGISTERED DIETITIAN
Credential: RD
Phone: 860-677-4429