Healthcare Provider Details

I. General information

NPI: 1124569959
Provider Name (Legal Business Name): SIMPLY DIETETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 N MAIN ST SUITE 1A
SHERIDAN WY
82801-3921
US

IV. Provider business mailing address

PO BOX 542
DAYTON WY
82836-0542
US

V. Phone/Fax

Practice location:
  • Phone: 208-866-2568
  • Fax:
Mailing address:
  • Phone: 208-866-2568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MS. JORDAN PAIGE MCCOY
Title or Position: OWNER REGISTERED DIETITIAN
Credential: MS RD LD
Phone: 208-866-2568