Provider Demographics
NPI:1932486966
Name:NUTRISOURCE NUTRITIONAL SERVICES, INC.
Entity type:Organization
Organization Name:NUTRISOURCE NUTRITIONAL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:912-222-7755
Mailing Address - Street 1:620 SEA ISLAND RD
Mailing Address - Street 2:PMB 273
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1767
Mailing Address - Country:US
Mailing Address - Phone:912-222-7755
Mailing Address - Fax:912-434-7018
Practice Address - Street 1:504 BEACHVIEW DR
Practice Address - Street 2:SUITE 2A
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-4740
Practice Address - Country:US
Practice Address - Phone:912-222-7755
Practice Address - Fax:912-434-7018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002579133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty