Provider Demographics
NPI:1417617655
Name:NUTRITION CUSTOM CARE
Entity Type:Organization
Organization Name:NUTRITION CUSTOM CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CDN, CLT
Authorized Official - Phone:732-936-5406
Mailing Address - Street 1:270 SAINT PAULS AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-5012
Mailing Address - Country:US
Mailing Address - Phone:917-238-4714
Mailing Address - Fax:
Practice Address - Street 1:270 SAINT PAULS AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-5012
Practice Address - Country:US
Practice Address - Phone:732-936-5406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty