Provider Demographics
NPI:1609219872
Name:MEDICAL NUTRITION SERVICES, LLC
Entity Type:Organization
Organization Name:MEDICAL NUTRITION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIMONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CNS
Authorized Official - Phone:480-204-6006
Mailing Address - Street 1:1198 W KELLY LN
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3772
Mailing Address - Country:US
Mailing Address - Phone:480-204-6006
Mailing Address - Fax:
Practice Address - Street 1:1198 W KELLY LN
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3772
Practice Address - Country:US
Practice Address - Phone:480-204-6006
Practice Address - Fax:480-436-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2013-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty