Healthcare Provider Details

I. General information

NPI: 1932123403
Provider Name (Legal Business Name): LBJ NUTRITION CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 COLUMBIA TURNPIKE
FLORHAM PARK NJ
07932
US

IV. Provider business mailing address

4 EXETER LN
MORRISTOWN NJ
07960-6340
US

V. Phone/Fax

Practice location:
  • Phone: 973-410-9700
  • Fax:
Mailing address:
  • Phone: 973-722-5861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number855316
License Number StateIL

VIII. Authorized Official

Name: MRS. ABBY J BLAUSTEIN
Title or Position: OWNER
Credential: MS, RD
Phone: 973-722-5861