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General NPI Number Information
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NPI Number | 1093036253
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Entity Type | Organization
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Legal Business Name | ENVISION NUTRITION INC.
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Dates
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Enumeration Date | 06/22/2010
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Last Update Date | 06/22/2010
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Provider Practice Location Address
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Address Line | 1922 HIGHWAY 74 N SUITE D
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City | TYRONE
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State | GA
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Zip | 30290-1660
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Country | US
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Telephone | 404-797-0528
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Fax |
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Provider Business Mailing Address
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Address Line | 1922 HIGHWAY 74 N SUITE D
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City | TYRONE
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State | GA
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Zip | 30290-1660
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Country | US
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Telephone | 404-797-0528
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. DONNA P DECAILLE
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Credential | RD
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Telephone | 404-797-0528
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | LD00262
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License Number State | GA
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