Provider Demographics
NPI:1679187827
Name:KJM DIETETICS LLC
Entity Type:Organization
Organization Name:KJM DIETETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLEE-JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WORMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:718-581-8659
Mailing Address - Street 1:102 STARDALE RD
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7064
Mailing Address - Country:US
Mailing Address - Phone:718-581-8659
Mailing Address - Fax:
Practice Address - Street 1:102 STARDALE RD
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-7064
Practice Address - Country:US
Practice Address - Phone:718-581-8659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty