Provider Demographics
NPI:1609253301
Name:COMMUNITY DIABETES AND NUTRITION SERVICES, LLC
Entity Type:Organization
Organization Name:COMMUNITY DIABETES AND NUTRITION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER AND PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKACS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BS, CDE
Authorized Official - Phone:570-604-6677
Mailing Address - Street 1:200 MAIN ST
Mailing Address - Street 2:SUITE L4
Mailing Address - City:BLAKELY
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1241
Mailing Address - Country:US
Mailing Address - Phone:570-604-6677
Mailing Address - Fax:570-307-4220
Practice Address - Street 1:200 MAIN ST
Practice Address - Street 2:SUITE L4
Practice Address - City:BLAKELY
Practice Address - State:PA
Practice Address - Zip Code:18447-1241
Practice Address - Country:US
Practice Address - Phone:570-604-6677
Practice Address - Fax:570-307-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000285133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1306930847OtherBLUE CROSS OF NORTHEAST PA
PA1306930847OtherBLUE CROSS OF NORTHEAST PA