Provider Demographics
NPI:1003550278
Name:MINTZ, RANDY (RD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:MINTZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MILL ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:WOODCLIFF LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07677-8142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 MILL ROAD EXT
Practice Address - Street 2:
Practice Address - City:WOODCLIFF LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07677-8142
Practice Address - Country:US
Practice Address - Phone:201-803-1871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ840538133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered