Healthcare Provider Details

I. General information

NPI: 1255089264
Provider Name (Legal Business Name): MY ISLAND NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SPRUCEWOOD DR
LEVITTOWN NY
11756-3813
US

IV. Provider business mailing address

107 SPRUCEWOOD DR
LEVITTOWN NY
11756-3813
US

V. Phone/Fax

Practice location:
  • Phone: 516-287-0364
  • Fax:
Mailing address:
  • Phone: 516-287-0364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRYAN STENGEL
Title or Position: DIETITIAN
Credential: RDN
Phone: 516-287-0364