Healthcare Provider Details

I. General information

NPI: 1003446709
Provider Name (Legal Business Name): MS NUTRITIONAL WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 NORTHERN BLVD STE 404
MANHASSET NY
11030-3022
US

IV. Provider business mailing address

1129 NORTHERN BLVD STE 404
MANHASSET NY
11030-3022
US

V. Phone/Fax

Practice location:
  • Phone: 516-851-0401
  • Fax: 516-740-0285
Mailing address:
  • Phone: 516-851-0401
  • Fax: 516-740-0285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MAHTAB SOLEIMANZADEH
Title or Position: REGISTERED DIETITIAN
Credential: RD, CDN
Phone: 516-851-0401