Provider Demographics
NPI:1376943126
Name:VINEYARD NUTRITION LLC
Entity Type:Organization
Organization Name:VINEYARD NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-627-3235
Mailing Address - Street 1:95 W TISBURY RD
Mailing Address - Street 2:
Mailing Address - City:EDGARTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02539-7183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:256 EDGARTOWN VINEYARD HAVEN RD
Practice Address - Street 2:
Practice Address - City:EDGARTOWN
Practice Address - State:MA
Practice Address - Zip Code:02539-6933
Practice Address - Country:US
Practice Address - Phone:508-627-3235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3260133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty