Provider Demographics
NPI:1346213212
Name:KINDERHOOK NUTRITION, LLC
Entity Type:Organization
Organization Name:KINDERHOOK NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANALLEN-BRASWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:518-758-8885
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:KINDERHOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12106-0003
Mailing Address - Country:US
Mailing Address - Phone:518-758-8885
Mailing Address - Fax:518-758-9390
Practice Address - Street 1:5 ROTHERMEL AVE
Practice Address - Street 2:
Practice Address - City:KINDERHOOK
Practice Address - State:NY
Practice Address - Zip Code:12106-2105
Practice Address - Country:US
Practice Address - Phone:518-758-8885
Practice Address - Fax:518-758-9390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006035-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9519E1Medicare ID - Type Unspecified