Provider Demographics
NPI:1063724193
Name:DOC NUTRITION CLINIC
Entity type:Organization
Organization Name:DOC NUTRITION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MSN, APRN
Authorized Official - Phone:203-269-2852
Mailing Address - Street 1:185 CENTER ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4100
Mailing Address - Country:US
Mailing Address - Phone:203-269-2852
Mailing Address - Fax:203-269-9852
Practice Address - Street 1:185 CENTER ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4100
Practice Address - Country:US
Practice Address - Phone:203-269-2852
Practice Address - Fax:203-269-9852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service