MEDICARE: WISE NUTRITION 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	133VN1005X	Renal Nutrition Registered Dietitian	ND5781	FL

General Provider Information

NPI Number	:	1255638797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE NUTRITION LLC

Provider Business Mailing Address
First Line	:	35 CAMBRIDGE TRCE
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-2471
Country	:	US
Telephone Number	:	386-675-0790
Fax Number	:	888-785-7846

Provider Business Practice Location Address
First Line	:	35 CAMBRIDGE TRCE
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-2471
Country	:	US
Telephone Number	:	386-675-0790
Fax Number	:	888-785-7846

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	MRS. NANCY M WISE
Credential	:	MS/RD/LD/N
Telephone Number	:	386-295-1265

Provider Enumeration Date	:	02/18/2011
Last Update Date	:	11/01/2011

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Directions to “WISE NUTRITION LLC ” Practice Location

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