Provider Demographics
NPI:1649749979
Name:KB MEDICAL NUTRITION THERAPY LLC
Entity Type:Organization
Organization Name:KB MEDICAL NUTRITION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:BALKUNAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-484-9808
Mailing Address - Street 1:197 JOHNNYCAKE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-2011
Mailing Address - Country:US
Mailing Address - Phone:860-484-9808
Mailing Address - Fax:
Practice Address - Street 1:500 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:HARWINTON
Practice Address - State:CT
Practice Address - Zip Code:06791-1506
Practice Address - Country:US
Practice Address - Phone:860-485-0405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001637OtherLICENSE