Healthcare Provider Details

I. General information

NPI: 1578864823
Provider Name (Legal Business Name): PHILADELPHIA NUTRITION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2026 CHESTNUT ST
PHILADELPHIA PA
19103-4446
US

IV. Provider business mailing address

2026 CHESTNUT ST
PHILADELPHIA PA
19103-4446
US

V. Phone/Fax

Practice location:
  • Phone: 215-431-0968
  • Fax:
Mailing address:
  • Phone: 215-431-0968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN003994
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDN003994
License Number StatePA

VIII. Authorized Official

Name: KEVIN O'MELIA
Title or Position: OWNER
Credential: M.S.
Phone: 215-431-0968