Healthcare Provider Details

I. General information

NPI: 1154141463
Provider Name (Legal Business Name): NUTRITION THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 E LLANO ESTACADO BLVD APT G
CLOVIS NM
88101-3999
US

IV. Provider business mailing address

2400 E LLANO ESTACADO BLVD APT 2406-G
CLOVIS NM
88101-3974
US

V. Phone/Fax

Practice location:
  • Phone: 904-504-5955
  • Fax:
Mailing address:
  • Phone: 904-504-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH BATES
Title or Position: REGISTERED DIETITIAN
Credential: RD
Phone: 904-504-5955