1457697260 NPI number — CERTIFIED NUTRITION CONSULTANTS, PLLC

Table of content: (NPI 1457697260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457697260 NPI number — CERTIFIED NUTRITION CONSULTANTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CERTIFIED NUTRITION CONSULTANTS, PLLC
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:
1457697260
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 RIO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNSVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78526-2002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-546-4898
Provider Business Mailing Address Fax Number:
956-517-1015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
855 W PRICE RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78520-8742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-546-4898
Provider Business Practice Location Address Fax Number:
956-517-1015
Provider Enumeration Date:
12/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BETANCOURT
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
956-546-4898

Provider Taxonomy Codes

  • Taxonomy code: 133VN1004X , with the licence number:  DT05843 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 150179305 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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