Provider Demographics
NPI:1063917433
Name:NUTRGEN LLC
Entity type:Organization
Organization Name:NUTRGEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:EL-KHATIB
Authorized Official - Suffix:
Authorized Official - Credentials:CNS
Authorized Official - Phone:301-703-9923
Mailing Address - Street 1:13110 GLEN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-8852
Mailing Address - Country:US
Mailing Address - Phone:301-703-9923
Mailing Address - Fax:
Practice Address - Street 1:13110 GLEN RD
Practice Address - Street 2:
Practice Address - City:NORTH POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20878-8852
Practice Address - Country:US
Practice Address - Phone:301-703-9923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4369133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDDX4369OtherMARYLAND BOARD OF DIETETIC PRACTICE- FOR EVA EL-KHATIB