Provider Demographics
NPI:1235863424
Name:SUSAN SULLIVAN NUTRITION LLC
Entity Type:Organization
Organization Name:SUSAN SULLIVAN NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:803-603-1700
Mailing Address - Street 1:257 AVENSONG DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7928
Mailing Address - Country:US
Mailing Address - Phone:803-603-1700
Mailing Address - Fax:
Practice Address - Street 1:257 AVENSONG DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7928
Practice Address - Country:US
Practice Address - Phone:803-603-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty