MEDICARE: EXCELLIS 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	:	1417718602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELLIS NUTRITION LLC

Provider Business Mailing Address
First Line	:	PO BOX 2572
Second Line	:
City	:	CEDAR HILL
State	:	TX
Zip	:	75106-2572
Country	:	US
Telephone Number	:	469-708-6940
Fax Number	:

Provider Business Practice Location Address
First Line	:	475 E FM 1382 UNIT 2572
Second Line	:
City	:	CEDAR HILL
State	:	TX
Zip	:	75106-5118
Country	:	US
Telephone Number	:	469-708-6940
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND REGISTERED DIETITIAN
Name	:	DR. STACIE VANESSA ELLIS
Credential	:	PHD, RDN, LD
Telephone Number	:	469-708-6940

Provider Enumeration Date	:	01/16/2024
Last Update Date	:	01/16/2024

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