Healthcare Provider Details

I. General information

NPI: 1093036253
Provider Name (Legal Business Name): ENVISION NUTRITION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 HIGHWAY 74 N SUITE D
TYRONE GA
30290-1660
US

IV. Provider business mailing address

1922 HIGHWAY 74 N SUITE D
TYRONE GA
30290-1660
US

V. Phone/Fax

Practice location:
  • Phone: 404-797-0528
  • Fax:
Mailing address:
  • Phone: 404-797-0528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD00262
License Number StateGA

VIII. Authorized Official

Name: MRS. DONNA P DECAILLE
Title or Position: EXECUTIVE DIRECTOR
Credential: RD
Phone: 404-797-0528