Healthcare Provider Details

I. General information

NPI: 1689260275
Provider Name (Legal Business Name): RENAL NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 ENTRADA WAY
ROUND ROCK TX
78681-1740
US

IV. Provider business mailing address

404 ENTRADA WAY
ROUND ROCK TX
78681-1740
US

V. Phone/Fax

Practice location:
  • Phone: 732-429-2886
  • Fax:
Mailing address:
  • Phone: 732-429-2886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: DHARTI SHAH
Title or Position: OWNER, REGISTERED DIETITIAN
Credential: RD, CLT
Phone: 732-429-2886