Provider Demographics
NPI:1235523432
Name:SPECIALTY NUTRITION AND HEALTH LLC
Entity Type:Organization
Organization Name:SPECIALTY NUTRITION AND HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:804-864-1998
Mailing Address - Street 1:2727 ENTERPRISE PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-6341
Mailing Address - Country:US
Mailing Address - Phone:804-864-1998
Mailing Address - Fax:804-864-1997
Practice Address - Street 1:2727 ENTERPRISE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-6341
Practice Address - Country:US
Practice Address - Phone:804-864-1998
Practice Address - Fax:804-864-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1003144133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ49365E417Medicare PIN