Healthcare Provider Details

I. General information

NPI: 1952058158
Provider Name (Legal Business Name): MNT DELTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 COURT SQ
LEXINGTON MS
39095-3628
US

IV. Provider business mailing address

208 COURT SQ
LEXINGTON MS
39095-3628
US

V. Phone/Fax

Practice location:
  • Phone: 216-633-8189
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MARVEN DENIS CANTAVE
Title or Position: REGISTERED DIETITIAN
Credential: RD
Phone: 216-633-8189