Provider Demographics
NPI:1215572854
Name:DIETITIANS OF PALM VALLEY
Entity Type:Organization
Organization Name:DIETITIANS OF PALM VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:PREVITE
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:724-816-5561
Mailing Address - Street 1:230 CANAL BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3745
Mailing Address - Country:US
Mailing Address - Phone:904-250-0075
Mailing Address - Fax:
Practice Address - Street 1:230 CANAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-3745
Practice Address - Country:US
Practice Address - Phone:904-250-0075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service