Provider Demographics
NPI:1639839087
Name:MADALYN DIABETES NUTRITION LLC
Entity Type:Organization
Organization Name:MADALYN DIABETES NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:MADALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CDCES
Authorized Official - Phone:862-262-8326
Mailing Address - Street 1:459 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-2282
Mailing Address - Country:US
Mailing Address - Phone:862-262-8326
Mailing Address - Fax:
Practice Address - Street 1:18-20 LACKAWANNA PLZ STE 200
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3642
Practice Address - Country:US
Practice Address - Phone:862-262-8326
Practice Address - Fax:973-333-4070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty