MEDICARE: DR. B CLINICAL NUTRITION

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	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1194660340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. B CLINICAL NUTRITION

Provider Business Mailing Address
First Line	:	38 NORTH ST
Second Line	:
City	:	MACHIAS
State	:	ME
Zip	:	04654-1123
Country	:	US
Telephone Number	:	207-271-0309
Fax Number	:

Provider Business Practice Location Address
First Line	:	38 NORTH ST
Second Line	:
City	:	MACHIAS
State	:	ME
Zip	:	04654-1123
Country	:	US
Telephone Number	:	207-271-0309
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. GINO BANCAYANVEGA
Credential	:	ND MS CNS LDN
Telephone Number	:	207-271-0309

Provider Enumeration Date	:	04/22/2026
Last Update Date	:	04/26/2026

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