Provider Demographics
NPI:1285040386
Name:PRESCRIPTIVE NUTRITION, LLC
Entity Type:Organization
Organization Name:PRESCRIPTIVE NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN, NUTRITIONIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KERSH
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:479-651-8547
Mailing Address - Street 1:3205 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2301
Mailing Address - Country:US
Mailing Address - Phone:479-651-8547
Mailing Address - Fax:
Practice Address - Street 1:3205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2301
Practice Address - Country:US
Practice Address - Phone:479-651-8547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0449133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty