Provider Demographics
NPI:1609266931
Name:BOSTON FUNCTIONAL NUTRITION
Entity Type:Organization
Organization Name:BOSTON FUNCTIONAL NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHEE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:617-650-7572
Mailing Address - Street 1:68 VIRGINIA FARME LN
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:MA
Mailing Address - Zip Code:01741-1302
Mailing Address - Country:US
Mailing Address - Phone:617-650-7572
Mailing Address - Fax:888-835-5844
Practice Address - Street 1:97 LOWELL RD
Practice Address - Street 2:MILLBROOK TARRY
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-1733
Practice Address - Country:US
Practice Address - Phone:617-650-7572
Practice Address - Fax:888-835-5844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2715133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty