Provider Demographics
NPI:1225220866
Name:NUTRITION 411 BEVERLY FORD RD LD LLC
Entity Type:Organization
Organization Name:NUTRITION 411 BEVERLY FORD RD LD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:RD LD
Authorized Official - Phone:706-589-1582
Mailing Address - Street 1:2425 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6127
Mailing Address - Country:US
Mailing Address - Phone:706-589-1582
Mailing Address - Fax:
Practice Address - Street 1:2425 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6127
Practice Address - Country:US
Practice Address - Phone:706-589-1582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000488133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Single Specialty