Provider Demographics
NPI:1073226403
Name:ELLIE KELSEY NUTRITION LLC
Entity Type:Organization
Organization Name:ELLIE KELSEY NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSEY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:732-570-1078
Mailing Address - Street 1:624 JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07762-1835
Mailing Address - Country:US
Mailing Address - Phone:732-570-1078
Mailing Address - Fax:
Practice Address - Street 1:1924 RTE 35 STE 9C
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3530
Practice Address - Country:US
Practice Address - Phone:732-570-1078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty