Provider Demographics
NPI:1710380910
Name:NUTRITION THERAPY NEW MEXICO LLC
Entity Type:Organization
Organization Name:NUTRITION THERAPY NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:WILLMS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:505-412-5983
Mailing Address - Street 1:2185 44TH ST
Mailing Address - Street 2:STE D
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-1750
Mailing Address - Country:US
Mailing Address - Phone:505-412-5983
Mailing Address - Fax:
Practice Address - Street 1:2185 44TH ST
Practice Address - Street 2:STE D
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-1750
Practice Address - Country:US
Practice Address - Phone:505-412-5983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-0659133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty