Healthcare Provider Details

I. General information

NPI: 1891801791
Provider Name (Legal Business Name): MEDICAL NUTRITIONAL THERAPISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 FINZER STREET #302
LOUISVILLE KY
40203
US

IV. Provider business mailing address

4210 FLAGSTAFF CV
FORT WAYNE IN
46815-4417
US

V. Phone/Fax

Practice location:
  • Phone: 800-245-9009
  • Fax: 260-489-5057
Mailing address:
  • Phone: 260-489-9009
  • Fax: 260-489-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JAMES A HOLB
Title or Position: OWNER/VICE PRESIDENT
Credential: RD LD CDE
Phone: 260-489-9009