Provider Demographics
NPI:1598253668
Name:123 NUTRITION, L.L.C.
Entity Type:Organization
Organization Name:123 NUTRITION, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED DIETITIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:STONER
Authorized Official - Suffix:II
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:704-691-5862
Mailing Address - Street 1:2715 GUSTY LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8001
Mailing Address - Country:US
Mailing Address - Phone:704-691-5862
Mailing Address - Fax:
Practice Address - Street 1:2715 GUSTY LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8001
Practice Address - Country:US
Practice Address - Phone:704-691-5862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005319133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty