Healthcare Provider Details

I. General information

NPI: 1972420123
Provider Name (Legal Business Name): OPEN TABLE NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S LEXINGTON ST STE 100
HARRISONVILLE MO
64701-2443
US

IV. Provider business mailing address

117 S LEXINGTON ST STE 100
HARRISONVILLE MO
64701-2443
US

V. Phone/Fax

Practice location:
  • Phone: 314-282-5181
  • Fax:
Mailing address:
  • Phone: 314-282-5181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JACLYN ALVAREZ
Title or Position: AUTHORIZED OFFICIAL
Credential: MS, RDN, CSOWM, LD
Phone: 314-282-5181