Healthcare Provider Details

I. General information

NPI: 1003120809
Provider Name (Legal Business Name): THA NATURAL NUTRITIONIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MILL PLAIN RD SUITE 1
DANBURY CT
06811-5171
US

IV. Provider business mailing address

103 MILL PLAIN RD SUITE 1
DANBURY CT
06811-5171
US

V. Phone/Fax

Practice location:
  • Phone: 203-790-4700
  • Fax: 203-790-4601
Mailing address:
  • Phone: 203-790-4700
  • Fax: 203-790-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00849120
License Number StateNY

VIII. Authorized Official

Name: MS. MARY BETH AUGUSTINE
Title or Position: DIRECTOR/OWNER
Credential: RD
Phone: 203-790-4700