MEDICARE: ELYSA DINZES 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
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1659903870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELYSA DINZES NUTRITION LLC

Provider Business Mailing Address
First Line	:	76 N HILLSIDE AVE
Second Line	:
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039-1110
Country	:	US
Telephone Number	:	917-837-0598
Fax Number	:

Provider Business Practice Location Address
First Line	:	66 W MOUNT PLEASANT AVE STE 205
Second Line	:
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039-2930
Country	:	US
Telephone Number	:	917-837-0598
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ELYSA FAITH DINZES
Credential	:	RD
Telephone Number	:	917-837-0598

Provider Enumeration Date	:	02/05/2020
Last Update Date	:	02/05/2020

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