=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588911143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUTRITION GIRLS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2012
-----------------------------------------------------
Last Update Date | 08/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 THAMES DRIVE
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-208-1959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 THAMES DRIVE
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED DIETITIAN
-----------------------------------------------------
Name | MRS. JENNIFER CSONTOS
-----------------------------------------------------
Credential | RD
-----------------------------------------------------
Telephone | 908-208-1959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------