=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962008573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST CHOICE NUTRITION CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2020
-----------------------------------------------------
Last Update Date | 12/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4722 PICKRIDGE CT
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77545-7529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-469-0155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4722 PICKRIDGE CT
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77545-7529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-469-0155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MELANIE THOMAS
-----------------------------------------------------
Credential | RDN, LD
-----------------------------------------------------
Telephone | 832-469-0155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------