Healthcare Provider Details

I. General information

NPI: 1124553375
Provider Name (Legal Business Name): MK-RDNUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 S FORT APACHE RD SUITE #100
LAS VEGAS NV
89148-5655
US

IV. Provider business mailing address

6040 S FORT APACHE RD STE 100
LAS VEGAS NV
89148-5613
US

V. Phone/Fax

Practice location:
  • Phone: 702-781-2577
  • Fax:
Mailing address:
  • Phone: 702-475-4007
  • Fax: 702-475-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number32302D1-0
License Number StateNV

VIII. Authorized Official

Name: MICHELLE KONSTANTARAKIS
Title or Position: PRESIDENT
Credential: R.D.
Phone: 702-589-1414