MEDICARE: NUTRIMENT GROUP, 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	711675	SC

General Provider Information

NPI Number	:	1447530829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUTRIMENT GROUP, LLC

Provider Business Mailing Address
First Line	:	3310 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3310 FOREST DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4024
Country	:	US
Telephone Number	:	803-782-0400
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LARRY J HEISLER
Credential	:
Telephone Number	:	803-782-0400

Provider Enumeration Date	:	08/17/2011
Last Update Date	:	08/17/2011

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