Provider Demographics
NPI:1588347462
Name:MNT SCIENTIFIC
Entity type:Organization
Organization Name:MNT SCIENTIFIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:LACKMANN
Authorized Official - Last Name:TRAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:909-653-3471
Mailing Address - Street 1:671 RIVER RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:MARKLEEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96120
Mailing Address - Country:US
Mailing Address - Phone:909-653-3471
Mailing Address - Fax:949-269-0134
Practice Address - Street 1:3079 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:909-653-3471
Practice Address - Fax:949-260-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-08
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty