=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386326551
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I HEART REAL FOOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 08/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 CARRIAGE WALK CT
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20879-5512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-306-7400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 CARRIAGE WALK CT
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20879-5512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-306-7400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NUTRITIONIST
-----------------------------------------------------
Name | MAKETA DIXON
-----------------------------------------------------
Credential | CNS, LDN
-----------------------------------------------------
Telephone | 240-306-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------