Provider Demographics
NPI:1225600430
Name:PHILADELPHIA NUTRITION AND WELLNESS, LLC
Entity Type:Organization
Organization Name:PHILADELPHIA NUTRITION AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:267-314-7675
Mailing Address - Street 1:451 HERMITAGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3301
Mailing Address - Country:US
Mailing Address - Phone:610-506-7112
Mailing Address - Fax:
Practice Address - Street 1:451 HERMITAGE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3301
Practice Address - Country:US
Practice Address - Phone:267-314-7675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty