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NPI Code Detail

MEDICARE: PROVIDENCE NUTRITION, LLC

MEDICARE: PROVIDENCE 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
1133N00000XNutritionist

General Provider Information

NPI Number : 1548775299
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROVIDENCE NUTRITION, LLC
Provider Business Mailing Address
First Line : 439 BENEFIT ST UNIT 1
Second Line :
City : PROVIDENCE
State : RI
Zip : 02903-2934
Country : US
Telephone Number : 401-262-0841
Fax Number :
Provider Business Practice Location Address
First Line : 439 BENEFIT ST UNIT 1
Second Line :
City : PROVIDENCE
State : RI
Zip : 02903-2934
Country : US
Telephone Number : 401-262-0841
Fax Number :
Authorized Official
Title or Position : MANAGER
Name : MR. NEIL BERANBAUM
Credential :
Telephone Number : 401-465-4222
Provider Enumeration Date : 12/04/2017
Last Update Date : 12/04/2017

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