Provider Demographics
NPI:1285903708
Name:ROSWELL NUTRITION LLC
Entity type:Organization
Organization Name:ROSWELL NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, L,D
Authorized Official - Phone:404-735-4850
Mailing Address - Street 1:5825 GLENRIDGE DR NE
Mailing Address - Street 2:BLDG 3, SUITE 101
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5387
Mailing Address - Country:US
Mailing Address - Phone:404-735-4850
Mailing Address - Fax:678-244-5350
Practice Address - Street 1:5825 GLENRIDGE DR NE
Practice Address - Street 2:BLDG 3, SUITE 101
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5387
Practice Address - Country:US
Practice Address - Phone:404-735-4850
Practice Address - Fax:678-244-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003732133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty