Healthcare Provider Details

I. General information

NPI: 1558123729
Provider Name (Legal Business Name): MIFTARI NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 BRIGHTON 12TH ST APT 1D
BROOKLYN NY
11235-4704
US

IV. Provider business mailing address

2990 BRIGHTON 12TH ST APT 1D
BROOKLYN NY
11235-4704
US

V. Phone/Fax

Practice location:
  • Phone: 718-916-3380
  • Fax:
Mailing address:
  • Phone: 718-916-3380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MR. ALTON MIFTARI
Title or Position: OWNER/REGISTERED DIETITIAN
Credential: MS, RD, CDN
Phone: 718-916-3380