Provider Demographics
NPI:1417718602
Name:EXCELLIS NUTRITION LLC
Entity Type:Organization
Organization Name:EXCELLIS NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND REGISTERED DIETITIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RDN, LD
Authorized Official - Phone:469-708-6940
Mailing Address - Street 1:PO BOX 2572
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75106-2572
Mailing Address - Country:US
Mailing Address - Phone:469-708-6940
Mailing Address - Fax:
Practice Address - Street 1:475 E FM 1382 UNIT 2572
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75106-5118
Practice Address - Country:US
Practice Address - Phone:469-708-6940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty