Provider Demographics
NPI:1316477813
Name:PROFESSIONAL NUTRITION SERVICES LLC
Entity type:Organization
Organization Name:PROFESSIONAL NUTRITION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATOSHA
Authorized Official - Middle Name:WILDER
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:662-836-4450
Mailing Address - Street 1:301 LEE ST
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-3705
Mailing Address - Country:US
Mailing Address - Phone:662-836-4450
Mailing Address - Fax:
Practice Address - Street 1:301 LEE ST
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038-3705
Practice Address - Country:US
Practice Address - Phone:662-836-4450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1613133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty