Healthcare Provider Details

I. General information

NPI: 1053486407
Provider Name (Legal Business Name): BRG DIETETICS & NUTRITION, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 PLYMOUTH ST
WEST HEMPSTEAD NY
11552-2450
US

IV. Provider business mailing address

383 PLYMOUTH ST
WEST HEMPSTEAD NY
11552-2450
US

V. Phone/Fax

Practice location:
  • Phone: 516-486-4569
  • Fax: 516-486-1792
Mailing address:
  • Phone: 516-486-4569
  • Fax: 516-486-1792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number000251
License Number StateNY

VIII. Authorized Official

Name: MRS. BONNIE RENEE GILLER
Title or Position: PRESIDENT REGISTERED DIETITIAN
Credential: MS, RD, CDN, CDE
Phone: 516-486-4569