Provider Demographics
NPI:1578185500
Name:JG NUTREND PROVIDERS PA
Entity Type:Organization
Organization Name:JG NUTREND PROVIDERS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:NAN
Authorized Official - Last Name:WHITMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-246-3424
Mailing Address - Street 1:PO BOX 27095
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2022
Mailing Address - Country:US
Mailing Address - Phone:346-246-4171
Mailing Address - Fax:
Practice Address - Street 1:425 HOLDERRIETH BLVD STE 212
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4552
Practice Address - Country:US
Practice Address - Phone:346-246-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning FacilityGroup - Single Specialty