MEDICARE: NUTRITIOUS CONCEPTS 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	DT80546	TX

General Provider Information

NPI Number	:	1942798491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUTRITIOUS CONCEPTS LLC

Provider Business Mailing Address
First Line	:	15922 ELDORADO PKWY
Second Line	:	STE 500-925
City	:	FRISCO
State	:	TX
Zip	:	75035-8783
Country	:	US
Telephone Number	:	972-379-8832
Fax Number	:

Provider Business Practice Location Address
First Line	:	15922 ELDORADO PKWY
Second Line	:	STE 500-925
City	:	FRISCO
State	:	TX
Zip	:	75035
Country	:	US
Telephone Number	:	972-379-8832
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	RUBI S ANJUM
Credential	:	RDN, LD
Telephone Number	:	972-379-8832

Provider Enumeration Date	:	04/30/2018
Last Update Date	:	11/05/2018

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