Provider Demographics
NPI:1972312775
Name:DAETITIAN LLC
Entity type:Organization
Organization Name:DAETITIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIKTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSINOVA
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:718-300-1544
Mailing Address - Street 1:18 DAFFODIL WAY
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-3592
Mailing Address - Country:US
Mailing Address - Phone:718-300-1544
Mailing Address - Fax:
Practice Address - Street 1:18 DAFFODIL WAY
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3592
Practice Address - Country:US
Practice Address - Phone:718-300-1544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty