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NPI Code Detail

MEDICARE: MEMPHIS NUTRITION GROUP, LLC

MEDICARE: MEMPHIS NUTRITION 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
1261Q00000XClinic/Center

General Provider Information

NPI Number : 1538799515
Entity Type Code : Organization
Provider Name (Legal Business Name) : MEMPHIS NUTRITION GROUP, LLC
Provider Business Mailing Address
First Line : 6263 POPLAR AVE STE 605
Second Line :
City : MEMPHIS
State : TN
Zip : 38119-4724
Country : US
Telephone Number : 901-343-6146
Fax Number : 901-328-1802
Provider Business Practice Location Address
First Line : 6263 POPLAR AVE STE 605
Second Line :
City : MEMPHIS
State : TN
Zip : 38119-4724
Country : US
Telephone Number : 901-343-6146
Fax Number : 901-328-1802
Authorized Official
Title or Position : CO-OWNER
Name : BLAIR MIZE
Credential : MS, RDN, CSSD, LDN
Telephone Number : 901-619-1942
Provider Enumeration Date : 01/18/2020
Last Update Date : 01/18/2020

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1619859782 — KATHRYN GRACE ANTONOPULOS MS, RD, LD
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Directions to “MEMPHIS NUTRITION GROUP, LLC ” Practice Location

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