Provider Demographics
NPI:1427683192
Name:TEACHING FENIX RDN CAFE LLC
Entity type:Organization
Organization Name:TEACHING FENIX RDN CAFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROVIDER, SINGLE MEMBER LLC
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LOPEZ-PETTORINO
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CDE
Authorized Official - Phone:973-206-2130
Mailing Address - Street 1:100 ENTERPRISE DR STE 301
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-2129
Mailing Address - Country:US
Mailing Address - Phone:973-206-2130
Mailing Address - Fax:973-385-1650
Practice Address - Street 1:100 ENTERPRISE DR STE 301
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-2129
Practice Address - Country:US
Practice Address - Phone:973-206-2130
Practice Address - Fax:973-385-1650
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CYNTHIA L LOPEZ-PETTORINO SOLE MBR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-03
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1376849117OtherTYPE 1 NPI FOR CYNTHIA L LOPEZ-PETTORINO