Provider Demographics
NPI:1578318390
Name:TEMPLE NUTRITION LLC
Entity Type:Organization
Organization Name:TEMPLE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHALESE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-491-9028
Mailing Address - Street 1:7441 MISTYDAWN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4772 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-1606
Practice Address - Country:US
Practice Address - Phone:919-491-9028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty