MEDICARE: CCNC 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	DT06856	TX

General Provider Information

NPI Number	:	1871781831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCNC NUTRITION, LLC.

Provider Business Mailing Address
First Line	:	19010 SPRING MEADOWS LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-3820
Country	:	US
Telephone Number	:	713-242-1122
Fax Number	:	866-450-4726

Provider Business Practice Location Address
First Line	:	17121 WESTHEIMER RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-1259
Country	:	US
Telephone Number	:	713-242-1122
Fax Number	:	866-450-4726

Authorized Official
Title or Position	:	REGISTERED & LICESNED DIETITIAN, OW
Name	:	MRS. COURTNEY ALLISON CAESAR
Credential	:	R.D., L.D.
Telephone Number	:	713-242-1122

Provider Enumeration Date	:	10/04/2007
Last Update Date	:	10/04/2007

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