Provider Demographics
NPI:1578324489
Name:EXPEDITION NUTRITION SERVICES LLC
Entity Type:Organization
Organization Name:EXPEDITION NUTRITION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KRONLAGE
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:907-513-7591
Mailing Address - Street 1:805 PENINSULA AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-6949
Mailing Address - Country:US
Mailing Address - Phone:907-513-7591
Mailing Address - Fax:
Practice Address - Street 1:805 PENINSULA AVE APT 8
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-6949
Practice Address - Country:US
Practice Address - Phone:907-513-7591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty