Healthcare Provider Details

I. General information

NPI: 1003451576
Provider Name (Legal Business Name): BERTA NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74A PARKWAY CT
BROOKLYN NY
11235-6113
US

IV. Provider business mailing address

724 AVENUE W
BROOKLYN NY
11223-5549
US

V. Phone/Fax

Practice location:
  • Phone: 732-508-0347
  • 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: BERTA YATCHA
Title or Position: PROVIDER
Credential: RD
Phone: 347-323-7025