1295058071 NPI number — SUMMIT NUTRITION SERVICES, LLC

Table of content: (NPI 1295058071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295058071 NPI number — SUMMIT NUTRITION SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT NUTRITION SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295058071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3027 MARIPOSA PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-487-9983
Provider Business Mailing Address Fax Number:
260-489-5072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3027 MARIPOSA PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-487-9983
Provider Business Practice Location Address Fax Number:
260-489-5072
Provider Enumeration Date:
03/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FERNANDO
Authorized Official First Name:
PERPETUA
Authorized Official Middle Name:
DELRINE
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
260-487-9983

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  37001987A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com