MEDICARE: VAN DUSEN NUTRITION

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	261QM1300X	Multi-Specialty Clinic/Center	3284	MA

General Provider Information

NPI Number	:	1952892788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAN DUSEN NUTRITION

Provider Business Mailing Address
First Line	:	1492 HIGHLAND AVE STE 4
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02492-2606
Country	:	US
Telephone Number	:	646-369-2255
Fax Number	:

Provider Business Practice Location Address
First Line	:	1492 HIGHLAND AVE STE 4
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02492-2606
Country	:	US
Telephone Number	:	646-369-2255
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LEIGH VAN DUSEN
Credential	:	MS, LDN
Telephone Number	:	781-343-1592

Provider Enumeration Date	:	05/29/2018
Last Update Date	:	05/29/2018

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