Provider Demographics
NPI:1285143651
Name:RURAL ROOTS NUTRITION PLLC
Entity type:Organization
Organization Name:RURAL ROOTS NUTRITION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CDN
Authorized Official - Phone:315-683-4263
Mailing Address - Street 1:1672 POMPEY CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FABIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13063-8703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1672 POMPEY CENTER RD
Practice Address - Street 2:
Practice Address - City:FABIUS
Practice Address - State:NY
Practice Address - Zip Code:13063-8703
Practice Address - Country:US
Practice Address - Phone:315-683-4263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5036296251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health