Provider Demographics
NPI:1992204564
Name:JACINTA NUTRITION AND DIABETES EDUCATION SERVICES LLC
Entity type:Organization
Organization Name:JACINTA NUTRITION AND DIABETES EDUCATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:GENTHNER
Authorized Official - Suffix:
Authorized Official - Credentials:MAS, RDN, LDN, CDE
Authorized Official - Phone:443-652-3674
Mailing Address - Street 1:21 WEST RD STE 103
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2307
Mailing Address - Country:US
Mailing Address - Phone:443-652-3674
Mailing Address - Fax:443-895-4165
Practice Address - Street 1:21 WEST RD STE 103
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-2307
Practice Address - Country:US
Practice Address - Phone:443-652-3674
Practice Address - Fax:443-895-4165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01213133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDDC74-0000OtherCAREFIRST BLUE CROSS BLUE SHIELD
13909823OtherCAQH PROVIEW