Provider Demographics
NPI:1578192597
Name:SMART MOUTH NUTRITION PLLC
Entity Type:Organization
Organization Name:SMART MOUTH NUTRITION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MANCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:RD/LDN
Authorized Official - Phone:407-719-0743
Mailing Address - Street 1:238 THORNTON LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3066
Mailing Address - Country:US
Mailing Address - Phone:407-719-0743
Mailing Address - Fax:
Practice Address - Street 1:238 THORNTON LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-3066
Practice Address - Country:US
Practice Address - Phone:407-719-0743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty