Provider Demographics
NPI:1992228381
Name:FRUITY VEGGIE NUTRITION
Entity type:Organization
Organization Name:FRUITY VEGGIE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-806-2281
Mailing Address - Street 1:3432 W 92ND PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2071
Mailing Address - Country:US
Mailing Address - Phone:786-578-7318
Mailing Address - Fax:
Practice Address - Street 1:3432 W 92ND PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-2071
Practice Address - Country:US
Practice Address - Phone:786-578-7318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6372133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL640540849040Medicaid