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General NPI Number Information
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NPI Number | 1720453814
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Entity Type | Organization
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Legal Business Name | BORDEAUX NUTRITION LLC
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Dates
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Enumeration Date | 12/01/2015
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Last Update Date | 12/04/2015
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Provider Practice Location Address
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Address Line | 66 CEDAR ST 305
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City | NEWINGTON
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State | CT
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Zip | 06111-2633
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Country | US
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Telephone | 860-523-0141
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Fax | 860-523-0141
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Provider Business Mailing Address
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Address Line | 66 CEDAR ST SUITE 305
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City | NEWINGTON
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State | CT
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Zip | 06111-2633
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Country | US
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Telephone | 860-523-0141
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Fax | 860-523-0141
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Authorized Official
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Title or Position | OWNER
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Name | MRS. RENEE J BORDEAUX
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Credential | RD, CDN, CPT
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Telephone | 860-978-9449
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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 | 000472
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License Number State | CT
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