Provider Demographics
NPI:1104944230
Name:NUTRITION SOLUTIONS OF QUINCY, INC.
Entity type:Organization
Organization Name:NUTRITION SOLUTIONS OF QUINCY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JANSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD LDN
Authorized Official - Phone:217-228-2413
Mailing Address - Street 1:2029 E 1850TH ST
Mailing Address - Street 2:
Mailing Address - City:COATSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62325-2102
Mailing Address - Country:US
Mailing Address - Phone:217-455-3491
Mailing Address - Fax:
Practice Address - Street 1:2029 E 1850TH ST
Practice Address - Street 2:
Practice Address - City:COATSBURG
Practice Address - State:IL
Practice Address - Zip Code:62325-2102
Practice Address - Country:US
Practice Address - Phone:217-242-3164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164000168133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015307Medicare UPIN
IL214898Medicare UPIN