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General NPI Number Information
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NPI Number | 1578185500
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Entity Type | Organization
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Legal Business Name | JG NUTREND PROVIDERS PA
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Dates
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Enumeration Date | 05/13/2020
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Last Update Date | 03/31/2021
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Provider Practice Location Address
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Address Line | 425 HOLDERRIETH BLVD STE 212
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City | TOMBALL
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State | TX
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Zip | 77375-4552
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Country | US
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Telephone | 346-246-4171
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 27095
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City | BELFAST
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State | ME
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Zip | 04915-2022
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Country | US
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Telephone | 346-246-4171
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MARY NAN WHITMEYER
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Credential |
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Telephone | 346-246-3424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0005X
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Taxonomy Name | Ambulatory Family Planning Facility
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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