Provider Demographics
NPI:1588372510
Name:MARY ELLEN B NUTRITION THERAPY LLC
Entity type:Organization
Organization Name:MARY ELLEN B NUTRITION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BANEVEDES
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CDCES
Authorized Official - Phone:559-572-2990
Mailing Address - Street 1:101 N IRWIN ST STE 205A
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-4579
Mailing Address - Country:US
Mailing Address - Phone:559-572-2990
Mailing Address - Fax:877-655-6301
Practice Address - Street 1:101 N IRWIN ST STE 205A
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4579
Practice Address - Country:US
Practice Address - Phone:559-572-2990
Practice Address - Fax:877-655-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty