Provider Demographics
NPI:1639683162
Name:COASTAL FAMILY NUTRITION
Entity Type:Organization
Organization Name:COASTAL FAMILY NUTRITION
Other - Org Name:KAREN MOUNTJOY PEDIATRIC NUTRITION AND DIETETICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUNTJOY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:603-674-2479
Mailing Address - Street 1:230 LAFAYETTE RD STE 13
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-5465
Mailing Address - Country:US
Mailing Address - Phone:603-674-2479
Mailing Address - Fax:603-590-7471
Practice Address - Street 1:230 LAFAYETTE RD STE 13
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5465
Practice Address - Country:US
Practice Address - Phone:603-674-2479
Practice Address - Fax:603-590-7471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0728133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1078302OtherNATIONAL REGISTRATION LD NUMBER
NH0728OtherSTATE LICENSURE