Healthcare Provider Details

I. General information

NPI: 1881024636
Provider Name (Legal Business Name): GREEN APPLE NUTRITION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 N POINT PKWY SUITE 64
ALPHARETTA GA
30022-1142
US

IV. Provider business mailing address

8685 VALDERAMA DR
DULUTH GA
30097-6649
US

V. Phone/Fax

Practice location:
  • Phone: 678-965-0119
  • Fax:
Mailing address:
  • Phone: 678-749-8634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberLD003621
License Number StateGA

VIII. Authorized Official

Name: NILAM GANGWAL
Title or Position: REGISTERED DIETITIAN
Credential: MS, RD, LD
Phone: 678-749-8634