Provider Demographics
NPI:1477704146
Name:AG NUTRITION SERVICES LLC
Entity Type:Organization
Organization Name:AG NUTRITION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CNSC
Authorized Official - Phone:626-768-8331
Mailing Address - Street 1:301 N HUDSON AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1634
Mailing Address - Country:US
Mailing Address - Phone:626-768-8331
Mailing Address - Fax:
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:626-768-8331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
925528133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467626135OtherMEDICARE NPI