MEDICARE: KELSEY PHEIFER 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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1376100933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELSEY PHEIFER NUTRITION LLC

Provider Business Mailing Address
First Line	:	2731 TIERGARTEN LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-5879
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2731 TIERGARTEN LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-5879
Country	:	US
Telephone Number	:	937-284-3145
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	KELSEY PHEIFER
Credential	:
Telephone Number	:	937-284-3145

Provider Enumeration Date	:	05/20/2019
Last Update Date	:	05/20/2019

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