Provider Demographics
NPI:1073086419
Name:PREMIER DIETETICS,LLC
Entity Type:Organization
Organization Name:PREMIER DIETETICS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:619-565-9126
Mailing Address - Street 1:12225 LEDBURY COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-3000
Mailing Address - Country:US
Mailing Address - Phone:813-534-8189
Mailing Address - Fax:
Practice Address - Street 1:9630 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5442
Practice Address - Country:US
Practice Address - Phone:813-534-8189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty