Provider Demographics
NPI:1285869974
Name:NUTRISOURCE NUTRITIONAL SERVICES
Entity type:Organization
Organization Name:NUTRISOURCE NUTRITIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GICZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CPT
Authorized Official - Phone:912-222-7755
Mailing Address - Street 1:620 SEA ISLAND RD
Mailing Address - Street 2:PMB 273
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1767
Mailing Address - Country:US
Mailing Address - Phone:912-222-7755
Mailing Address - Fax:912-264-4071
Practice Address - Street 1:3226 HAMPTON AVE STE F
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4252
Practice Address - Country:US
Practice Address - Phone:912-222-7755
Practice Address - Fax:912-264-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-25
Last Update Date:2009-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002579133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
931505OtherCOMMISSION ON DIETETIC REGISTRATION
00931505OtherAMERICAN DIETETIC ASSOCIATION
GALD002579OtherLICENSED DIETITIAN
T118230OtherAMERICAN COUNCIL ON EXERCISE PERSONAL TRAINER