Provider Demographics
NPI:1124569959
Name:SIMPLY DIETETICS, LLC
Entity Type:Organization
Organization Name:SIMPLY DIETETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:PAIGE
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD LD
Authorized Official - Phone:208-866-2568
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WY
Mailing Address - Zip Code:82836-0542
Mailing Address - Country:US
Mailing Address - Phone:208-866-2568
Mailing Address - Fax:
Practice Address - Street 1:172 N MAIN ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3921
Practice Address - Country:US
Practice Address - Phone:208-866-2568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty