Provider Demographics
NPI:1508195017
Name:JERSEY SHORE NUTRITION
Entity Type:Organization
Organization Name:JERSEY SHORE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LENORE
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:732-822-7117
Mailing Address - Street 1:315 PHILADELPHIA AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-3354
Mailing Address - Country:US
Mailing Address - Phone:732-822-7117
Mailing Address - Fax:732-240-1304
Practice Address - Street 1:129 ROUTE 37 W
Practice Address - Street 2:SUITE 3
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6435
Practice Address - Country:US
Practice Address - Phone:732-822-7117
Practice Address - Fax:732-240-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ701182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty