Provider Demographics
NPI:1508180829
Name:ANDERSONS NUTRITION
Entity Type:Organization
Organization Name:ANDERSONS NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:H
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:602-770-7611
Mailing Address - Street 1:257 W UWCHLAN AVE STE 218
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-3587
Mailing Address - Country:US
Mailing Address - Phone:602-770-7611
Mailing Address - Fax:
Practice Address - Street 1:4700 S MILL AVE STE B7
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-6736
Practice Address - Country:US
Practice Address - Phone:602-770-7611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2021-12-18
Deactivation Date:2018-06-11
Deactivation Code:
Reactivation Date:2019-04-24
Provider Licenses
StateLicense IDTaxonomies
AZ915444133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty