Provider Demographics
NPI:1134462328
Name:J&M NUTRITIONAL CONSULTING SERVICES, LLC
Entity Type:Organization
Organization Name:J&M NUTRITIONAL CONSULTING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:706-267-7479
Mailing Address - Street 1:3522 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-5732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4053 JIMMIE DYESS PKWY STE B
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9472
Practice Address - Country:US
Practice Address - Phone:706-267-7479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000433305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization