Healthcare Provider Details

I. General information

NPI: 1508052085
Provider Name (Legal Business Name): HEALTH & NUTRITION SERVICE OF RACINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 RAPIDS DR
RACINE WI
53404-2011
US

IV. Provider business mailing address

2316 RAPIDS DR
RACINE WI
53404-2011
US

V. Phone/Fax

Practice location:
  • Phone: 262-637-7750
  • Fax: 262-637-7926
Mailing address:
  • Phone: 262-637-7750
  • Fax: 262-637-7926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARGIE CARRINGTON
Title or Position: EXECUTIVE DIRECTOR
Credential: R.D.
Phone: 262-637-7750