Provider Demographics
NPI:1124553375
Name:MK-RDNUTRITION
Entity Type:Organization
Organization Name:MK-RDNUTRITION
Other - Org Name:CREATING A NEW NORM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KONSTANTARAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:702-589-1414
Mailing Address - Street 1:9995 CATSEYE COVE CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-7203
Mailing Address - Country:US
Mailing Address - Phone:702-589-1414
Mailing Address - Fax:
Practice Address - Street 1:6040 S FORT APACHE RD
Practice Address - Street 2:SUITE #100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5655
Practice Address - Country:US
Practice Address - Phone:702-781-2577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV32302D1-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV32302D1-0OtherNV DIETITIAN LICENSE