Provider Demographics
NPI:1578864823
Name:PHILADELPHIA NUTRITION CENTER, LLC
Entity Type:Organization
Organization Name:PHILADELPHIA NUTRITION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'MELIA
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:215-431-0968
Mailing Address - Street 1:2026 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-4446
Mailing Address - Country:US
Mailing Address - Phone:215-431-0968
Mailing Address - Fax:
Practice Address - Street 1:2026 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-4446
Practice Address - Country:US
Practice Address - Phone:215-431-0968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003994133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA242571Medicare PIN