Provider Demographics
NPI:1528660099
Name:TAVARES MEDICAL NUTRITION THERAPY LLC
Entity type:Organization
Organization Name:TAVARES MEDICAL NUTRITION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVARES
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:201-704-4654
Mailing Address - Street 1:1100 AVENUE AT PORT IMPERIAL APT 910
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-6303
Mailing Address - Country:US
Mailing Address - Phone:201-704-4654
Mailing Address - Fax:
Practice Address - Street 1:1100 AVENUE AT PORT IMPERIAL APT 910
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-6303
Practice Address - Country:US
Practice Address - Phone:201-704-4654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty