Healthcare Provider Details

I. General information

NPI: 1255163119
Provider Name (Legal Business Name): PHILADELPHIA FUNCTIONAL NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 W LANCASTER AVE STE 215
DEVON PA
19333-1585
US

IV. Provider business mailing address

237 W LANCASTER AVE STE 215
DEVON PA
19333-1585
US

V. Phone/Fax

Practice location:
  • Phone: 484-693-0660
  • Fax: 484-643-4500
Mailing address:
  • Phone: 484-693-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: RACHEL HERSHBERGER
Title or Position: OWNER
Credential: CNS LDN
Phone: 484-693-0660