MEDICARE: WAYNE 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	DN004453	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1639470354	OTHER	PA	PROVIDER NPI

General Provider Information

NPI Number	:	1942678842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAYNE NUTRITION, LLC

Provider Business Mailing Address
First Line	:	175 STRAFFORD AVE
Second Line	:	SUITE ONE
City	:	WAYNE
State	:	PA
Zip	:	19087-3317
Country	:	US
Telephone Number	:	484-253-1082
Fax Number	:

Provider Business Practice Location Address
First Line	:	175 STRAFFORD AVE
Second Line	:	SUITE ONE
City	:	WAYNE
State	:	PA
Zip	:	19087-3317
Country	:	US
Telephone Number	:	484-253-1082
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS KELLY ANN STROGEN
Credential	:	MS, RD, LDN
Telephone Number	:	484-253-1082

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	09/09/2015

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