Healthcare Provider Details

I. General information

NPI: 1902220692
Provider Name (Legal Business Name): PEDIATRIC NUTRITION SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2014
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38731 RICKARD RD
LOVETTSVILLE VA
20180-3115
US

IV. Provider business mailing address

38731 RICKARD RD
LOVETTSVILLE VA
20180-3115
US

V. Phone/Fax

Practice location:
  • Phone: 703-727-6100
  • Fax:
Mailing address:
  • Phone: 703-727-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number676968
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number633
License Number StateWV

VIII. Authorized Official

Name: SHEREE A HUGHES
Title or Position: PEDIATRIC DIETITIAN
Credential: RD, LD
Phone: 703-727-6100