Healthcare Provider Details

I. General information

NPI: 1417613381
Provider Name (Legal Business Name): HAYNES NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 SUMMERSTONE BND
BYRON GA
31008-6520
US

IV. Provider business mailing address

244 SUMMERSTONE BND
BYRON GA
31008-6520
US

V. Phone/Fax

Practice location:
  • Phone: 678-634-8620
  • Fax:
Mailing address:
  • Phone: 678-634-8620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RACHEL HAYNES
Title or Position: REGISTERED DIETITIAN
Credential: RDN
Phone: 678-634-8620