MEDICARE: COMBINED NUTRITION SOLUTIONS 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8KLR2	OTHER	FL	BCBS FB ID#

General Provider Information

NPI Number	:	1578136032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMBINED NUTRITION SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	78 W 11TH ST
Second Line	:
City	:	ATLANTIC BEACH
State	:	FL
Zip	:	32233-3461
Country	:	US
Telephone Number	:	919-951-4345
Fax Number	:

Provider Business Practice Location Address
First Line	:	6817 SOUTHPOINT PKWY STE 1203
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-6296
Country	:	US
Telephone Number	:	919-951-4345
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JENNIE LAUREN BUTLER
Credential	:	PHD, RDN, LDN
Telephone Number	:	919-951-4345

Provider Enumeration Date	:	07/22/2021
Last Update Date	:	07/22/2021

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