Provider Demographics
NPI:1326197500
Name:PROFESSIONAL NUTRITION SYSTEMS, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL NUTRITION SYSTEMS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:S
Authorized Official - Last Name:POLMANTEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-897-2260
Mailing Address - Street 1:7600 N 16TH ST
Mailing Address - Street 2:SUITE 140 ROOM 1
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4431
Mailing Address - Country:US
Mailing Address - Phone:480-897-2260
Mailing Address - Fax:480-897-2274
Practice Address - Street 1:7600 N 16TH ST
Practice Address - Street 2:SUITE 140 ROOM 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4431
Practice Address - Country:US
Practice Address - Phone:480-897-2260
Practice Address - Fax:480-897-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4547130001Medicare ID - Type UnspecifiedARIZONA