Provider Demographics
NPI:1235905845
Name:THE DIETITIAN DOCTOR, LLC
Entity Type:Organization
Organization Name:THE DIETITIAN DOCTOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KINDANN
Authorized Official - Middle Name:MCMAHAN STONE
Authorized Official - Last Name:FAWCETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RD, LD
Authorized Official - Phone:501-605-0310
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:AR
Mailing Address - Zip Code:72007-0100
Mailing Address - Country:US
Mailing Address - Phone:501-605-3683
Mailing Address - Fax:
Practice Address - Street 1:305 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3034
Practice Address - Country:US
Practice Address - Phone:501-605-0310
Practice Address - Fax:501-605-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty