Provider Demographics
NPI:1619919263
Name:MEDICAL NUTRITIONAL THERAPISTS, INC
Entity Type:Organization
Organization Name:MEDICAL NUTRITIONAL THERAPISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLB
Authorized Official - Suffix:
Authorized Official - Credentials:RD,LD,CDE
Authorized Official - Phone:260-489-9009
Mailing Address - Street 1:4210 FLAGSTAFF CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4417
Mailing Address - Country:US
Mailing Address - Phone:260-489-9009
Mailing Address - Fax:260-489-5057
Practice Address - Street 1:4210 FLAGSTAFF CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4417
Practice Address - Country:US
Practice Address - Phone:260-489-9009
Practice Address - Fax:260-489-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2465612Medicaid
INQ51183Medicare UPIN
IN213960Medicare NSC
OHME9344321Medicare ID - Type UnspecifiedMEDICARE GROUP NO.