Healthcare Provider Details

I. General information

NPI: 1578380333
Provider Name (Legal Business Name): PEDIATRIC NUTRITION OF SOUTHERN NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3148 ECKING AVE
HENDERSON NV
89044-0291
US

IV. Provider business mailing address

401 RYLAND ST STE 200A
RENO NV
89502-1643
US

V. Phone/Fax

Practice location:
  • Phone: 702-813-4318
  • Fax:
Mailing address:
  • Phone: 702-813-4318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ADAM CISEK
Title or Position: REGISTERED DIETITIAN
Credential: RD
Phone: 702-813-4318