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General NPI Number Information
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NPI Number | 1124569959
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Entity Type | Organization
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Legal Business Name | SIMPLY DIETETICS, LLC
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Dates
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Enumeration Date | 03/13/2017
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Last Update Date | 03/13/2017
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Provider Practice Location Address
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Address Line | 172 N MAIN ST SUITE 1A
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City | SHERIDAN
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State | WY
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Zip | 82801-3921
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Country | US
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Telephone | 208-866-2568
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 542
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City | DAYTON
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State | WY
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Zip | 82836-0542
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Country | US
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Telephone | 208-866-2568
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Fax |
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Authorized Official
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Title or Position | OWNER REGISTERED DIETITIAN
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Name | MS. JORDAN PAIGE MCCOY
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Credential | MS RD LD
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Telephone | 208-866-2568
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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