1265778187 NPI number — WHOLESOME NUTRITION, LLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265778187 NPI number — WHOLESOME NUTRITION, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHOLESOME NUTRITION, 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:
1265778187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 GREENHILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOW GROVE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19090-2812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-576-6305
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 HORSHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSHAM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19044-2140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-675-4535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCKINNEY
Authorized Official First Name:
CASEY
Authorized Official Middle Name:
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
717-576-6305

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  DN003959 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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