Provider Demographics
NPI:1609260454
Name:NUTRITION AND FITNESS PROFESSIONAL, LLC
Entity Type:Organization
Organization Name:NUTRITION AND FITNESS PROFESSIONAL, LLC
Other - Org Name:NUTRITION AND FITNESS PROFESSIONAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GOCHNOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MED, RD, LD, CPT
Authorized Official - Phone:281-757-8139
Mailing Address - Street 1:2205 N LAMAR BLVD UNIT 211
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-4938
Mailing Address - Country:US
Mailing Address - Phone:281-757-8139
Mailing Address - Fax:888-965-4398
Practice Address - Street 1:2205 N LAMAR BLVD UNIT 211
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-4938
Practice Address - Country:US
Practice Address - Phone:281-757-8139
Practice Address - Fax:888-965-4398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Multi-Specialty
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports DieteticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3689366Medicaid