Provider Demographics
NPI:1699217885
Name:MODERN MEDICAL NUTRITION THERAPY, LLC
Entity type:Organization
Organization Name:MODERN MEDICAL NUTRITION THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OVONLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MPH, MS, RDN, LMNT,
Authorized Official - Phone:402-618-0209
Mailing Address - Street 1:6554 S 117TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5726
Mailing Address - Country:US
Mailing Address - Phone:402-618-0209
Mailing Address - Fax:402-905-0321
Practice Address - Street 1:530 S 13TH ST
Practice Address - Street 2:STE 100
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68508-2710
Practice Address - Country:US
Practice Address - Phone:402-618-0209
Practice Address - Fax:402-905-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-05
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE752133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty