MEDICARE: ETHNIK NUTRITION PRACTICE LLC

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	:	1073258026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHNIK NUTRITION PRACTICE LLC

Provider Business Mailing Address
First Line	:	105 W 125TH ST FRNT 1
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10027-4444
Country	:	US
Telephone Number	:	646-245-1945
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 W 125TH ST FRNT 1
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10027-4444
Country	:	US
Telephone Number	:	646-245-1945
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	JOSEPHINE BINTU KATOBO
Credential	:	RD
Telephone Number	:	646-245-1945

Provider Enumeration Date	:	05/04/2022
Last Update Date	:	03/11/2023

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