Healthcare Provider Details

I. General information

NPI: 1093184640
Provider Name (Legal Business Name): MOHAWK VALLEY NUTRITIONAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 ONEIDA ST
UTICA NY
13501-6311
US

IV. Provider business mailing address

2600 ONEIDA ST
UTICA NY
13501-6311
US

V. Phone/Fax

Practice location:
  • Phone: 315-732-9368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0050941
License Number StateNY

VIII. Authorized Official

Name: PRIYA M MATHEW
Title or Position: OWNER
Credential:
Phone: 315-732-9368