Healthcare Provider Details

I. General information

NPI: 1548775299
Provider Name (Legal Business Name): PROVIDENCE NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 BENEFIT ST UNIT 1
PROVIDENCE RI
02903-2934
US

IV. Provider business mailing address

439 BENEFIT ST UNIT 1
PROVIDENCE RI
02903-2934
US

V. Phone/Fax

Practice location:
  • Phone: 401-262-0841
  • Fax:
Mailing address:
  • Phone: 401-262-0841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MR. NEIL BERANBAUM
Title or Position: MANAGER
Credential:
Phone: 401-465-4222