=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033539697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEANNINE ANDRE-BURNS NUTRITION SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2014
-----------------------------------------------------
Last Update Date | 04/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9408 FLATLANDS AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11236-3742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-305-4425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1530 UNION ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11213-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-305-4425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JEANNINE ANDRE-BURNS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 860-305-4425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | 16130
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------