Healthcare Provider Details

I. General information

NPI: 1861896441
Provider Name (Legal Business Name): PREVENTATIVE NUTRITION SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2014
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 E VILLA MARIA RD
BRYAN TX
77802-2542
US

IV. Provider business mailing address

PO BOX 2238
BRYAN TX
77806-2238
US

V. Phone/Fax

Practice location:
  • Phone: 979-353-1126
  • Fax: 979-530-9551
Mailing address:
  • Phone: 979-353-1126
  • Fax: 979-530-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JESSIANNA R SAVILLE
Title or Position: OWNER
Credential: M.S., R.D., L.D.,
Phone: 979-353-1126