Provider Demographics
NPI:1578635439
Name:SHASTA NUTRITION SERVICES
Entity Type:Organization
Organization Name:SHASTA NUTRITION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MERL
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-355-5820
Mailing Address - Street 1:PO BOX 993503
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-3503
Mailing Address - Country:US
Mailing Address - Phone:530-355-5820
Mailing Address - Fax:
Practice Address - Street 1:9225 PLACER RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2364
Practice Address - Country:US
Practice Address - Phone:530-355-5820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition