Provider Demographics
NPI:1598268229
Name:FIRST STATE NUTRITION LLC
Entity Type:Organization
Organization Name:FIRST STATE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-454-1230
Mailing Address - Street 1:1536 KIRKWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-5716
Mailing Address - Country:US
Mailing Address - Phone:302-454-1230
Mailing Address - Fax:302-454-5855
Practice Address - Street 1:910 N UNION ST STE 2
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-5334
Practice Address - Country:US
Practice Address - Phone:302-454-1230
Practice Address - Fax:302-454-5855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN0000617133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty