Provider Demographics
NPI:1528462223
Name:MY SIGNATURE NUTRITION, LLC
Entity type:Organization
Organization Name:MY SIGNATURE NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:UPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, RD, LD
Authorized Official - Phone:903-312-8906
Mailing Address - Street 1:5620 OLD BULLARD RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4358
Mailing Address - Country:US
Mailing Address - Phone:903-312-8906
Mailing Address - Fax:
Practice Address - Street 1:5620 OLD BULLARD RD
Practice Address - Street 2:SUITE 125
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4358
Practice Address - Country:US
Practice Address - Phone:903-312-8906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82055133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty