MEDICARE: OUELLETTE 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	:	1760076178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUELLETTE NUTRITION LLC

Provider Business Mailing Address
First Line	:	22 CARSON WAY
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-1847
Country	:	US
Telephone Number	:	860-222-0867
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 CARSON WAY
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-1847
Country	:	US
Telephone Number	:	860-222-0867
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGING MEMBER
Name	:	MICHAEL OUELLETTE
Credential	:	RDN, CDN
Telephone Number	:	860-222-0867

Provider Enumeration Date	:	02/25/2021
Last Update Date	:	02/25/2021

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