Provider Demographics
NPI:1134480528
Name:PROFESSIONAL ADVANTAGE NUTRITION AND FITNESS, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL ADVANTAGE NUTRITION AND FITNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:201-446-3736
Mailing Address - Street 1:201 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07075-1906
Mailing Address - Country:US
Mailing Address - Phone:201-446-3736
Mailing Address - Fax:201-438-7174
Practice Address - Street 1:341 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073-1717
Practice Address - Country:US
Practice Address - Phone:201-446-3736
Practice Address - Fax:201-438-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-03
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ942839133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty