Provider Demographics
NPI:1063596880
Name:CUSTOM DIETETICS, PC
Entity type:Organization
Organization Name:CUSTOM DIETETICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALLYSON
Authorized Official - Middle Name:ERICA
Authorized Official - Last Name:ODACHOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDN
Authorized Official - Phone:716-626-7415
Mailing Address - Street 1:2801 WEHRLE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7381
Mailing Address - Country:US
Mailing Address - Phone:716-626-7415
Mailing Address - Fax:716-632-0389
Practice Address - Street 1:2801 WEHRLE DR STE 4
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7381
Practice Address - Country:US
Practice Address - Phone:716-626-7415
Practice Address - Fax:716-632-0389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133V00000X
NY005917-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100346538Medicare PIN