Provider Demographics
NPI:1003011602
Name:AM NUTRITION SERVICES
Entity Type:Organization
Organization Name:AM NUTRITION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MCCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:623-399-6825
Mailing Address - Street 1:18001 N 79TH AVE STE A12
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8398
Mailing Address - Country:US
Mailing Address - Phone:623-399-6825
Mailing Address - Fax:623-505-3474
Practice Address - Street 1:18001 N 79TH AVE STE A12
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-399-6825
Practice Address - Fax:623-505-3474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ875272133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ547661Medicaid
DO6134OtherPTAN
AZ547661Medicaid