Provider Demographics
NPI:1609104058
Name:YOUR DIETITIAN LLC
Entity Type:Organization
Organization Name:YOUR DIETITIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOMFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CSR, LD
Authorized Official - Phone:770-356-9468
Mailing Address - Street 1:908 NEEDLETOP CT
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4315
Mailing Address - Country:US
Mailing Address - Phone:770-356-9468
Mailing Address - Fax:678-547-3156
Practice Address - Street 1:2758 FELTON DR
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3604
Practice Address - Country:US
Practice Address - Phone:770-356-9468
Practice Address - Fax:678-547-3156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001151133V00000X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty