MEDICARE: NUTRITION SERVICE SPECIALISTS 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	004000	GA

General Provider Information

NPI Number	:	1447613914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUTRITION SERVICE SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	1306 LAYOR CT
Second Line	:
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-1876
Country	:	US
Telephone Number	:	770-703-5053
Fax Number	:	770-703-5053

Provider Business Practice Location Address
First Line	:	1306 LAYOR CT
Second Line	:
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-1876
Country	:	US
Telephone Number	:	770-703-5053
Fax Number	:	770-703-5053

Authorized Official
Title or Position	:	OWNER
Name	:	MARY KATHERINE GAROFALO
Credential	:	PHD, MPH, RD/LD
Telephone Number	:	770-703-5053

Provider Enumeration Date	:	04/01/2016
Last Update Date	:	04/01/2016

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