Provider Demographics
NPI:1316564909
Name:KIDNEY NUTRITION SPECIALIST LLC
Entity Type:Organization
Organization Name:KIDNEY NUTRITION SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JADEDA
Authorized Official - Middle Name:DARWASHIA
Authorized Official - Last Name:HOOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:770-568-0162
Mailing Address - Street 1:213 HIGHLAND HILLS RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-5429
Mailing Address - Country:US
Mailing Address - Phone:770-568-0162
Mailing Address - Fax:
Practice Address - Street 1:213 HIGHLAND HILLS RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-5429
Practice Address - Country:US
Practice Address - Phone:770-568-0162
Practice Address - Fax:770-580-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty