Healthcare Provider Details

I. General information

NPI: 1760850390
Provider Name (Legal Business Name): MCDONOUGH NUTRITIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6827 4TH ST NW #104
WASHINGTON DC
20012-1900
US

IV. Provider business mailing address

6827 4TH ST NW #104
WASHINGTON DC
20012-1900
US

V. Phone/Fax

Practice location:
  • Phone: 202-509-6991
  • Fax:
Mailing address:
  • Phone: 202-509-6991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNU89
License Number StateDC

VIII. Authorized Official

Name: MRS. LIBIA MCDONOUGH
Title or Position: NUTRITIONIST
Credential: MS LC
Phone: 202-509-6991