1851785380 NPI number — ELIZABETH MADISON NUTRITION, PLLC

Table of content: (NPI 1851785380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851785380 NPI number — ELIZABETH MADISON NUTRITION, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELIZABETH MADISON NUTRITION, 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:
1851785380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22919 MERRICK BLVD
Provider Second Line Business Mailing Address:
#226
Provider Business Mailing Address City Name:
LAURELTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11413-2108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-276-6037
Provider Business Mailing Address Fax Number:
855-947-3783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13333 BROOKVILLE BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 229C
Provider Business Practice Location Address City Name:
ROSEDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-958-9958
Provider Business Practice Location Address Fax Number:
855-947-3783
Provider Enumeration Date:
03/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MADISON
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
855-958-9958

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 00800548 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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