Provider Demographics
NPI:1376246173
Name:JORDAN MCCOY NUTRITION LLC
Entity Type:Organization
Organization Name:JORDAN MCCOY NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, RDN, CDCES
Authorized Official - Phone:307-752-7280
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WY
Mailing Address - Zip Code:82836-0542
Mailing Address - Country:US
Mailing Address - Phone:307-752-7280
Mailing Address - Fax:
Practice Address - Street 1:618 HEATHER LANE
Practice Address - Street 2:
Practice Address - City:RANCHESTER
Practice Address - State:WY
Practice Address - Zip Code:82839
Practice Address - Country:US
Practice Address - Phone:307-752-7280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty