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General NPI Number Information
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NPI Number | 1952892788
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Entity Type | Organization
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Legal Business Name | VAN DUSEN NUTRITION
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Dates
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Enumeration Date | 05/29/2018
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Last Update Date | 05/29/2018
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Provider Practice Location Address
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Address Line | 1492 HIGHLAND AVE STE 4
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City | NEEDHAM
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State | MA
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Zip | 02492-2606
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Country | US
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Telephone | 646-369-2255
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Fax |
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Provider Business Mailing Address
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Address Line | 1492 HIGHLAND AVE STE 4
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City | NEEDHAM
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State | MA
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Zip | 02492-2606
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Country | US
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Telephone | 646-369-2255
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LEIGH VAN DUSEN
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Credential | MS, LDN
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Telephone | 781-343-1592
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 3284
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License Number State | MA
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