Provider Demographics
NPI:1740403054
Name:TOTAL NUTRITION THERAPY INC
Entity Type:Organization
Organization Name:TOTAL NUTRITION THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENTZION
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-820-7411
Mailing Address - Street 1:16644 E. JOHNSON DR. SUITE B
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91745-2412
Mailing Address - Country:US
Mailing Address - Phone:714-777-8794
Mailing Address - Fax:714-777-8773
Practice Address - Street 1:16644 E. JOHNSON DR. SUITE B
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91745-2412
Practice Address - Country:US
Practice Address - Phone:714-777-8794
Practice Address - Fax:714-777-8773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03062FMedicaid
CADME03062FMedicaid