Provider Demographics
NPI:1013555721
Name:MAJOR LEAGUE NUTRITION
Entity Type:Organization
Organization Name:MAJOR LEAGUE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHENARD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:617-582-9485
Mailing Address - Street 1:25 NEW CHARDON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-4774
Mailing Address - Country:US
Mailing Address - Phone:617-582-9485
Mailing Address - Fax:
Practice Address - Street 1:25 NEW CHARDON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4774
Practice Address - Country:US
Practice Address - Phone:617-582-9485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty