MEDICARE: SILVER STATE NUTRITION LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1003960550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SILVER STATE NUTRITION LLP

Provider Business Mailing Address
First Line	:	141 PLANTATION DR
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89703-5411
Country	:	US
Telephone Number	:	775-888-9510
Fax Number	:

Provider Business Practice Location Address
First Line	:	141 PLANTATION DR
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89703-5411
Country	:	US
Telephone Number	:	775-888-9510
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	MRS. JODI ANN PETTERSEN
Credential	:	R.D.
Telephone Number	:	775-888-9510

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	08/22/2020

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