Provider Demographics
NPI:1760027221
Name:FUNCTIONAL DIETETICS OF TEXAS, LLC
Entity Type:Organization
Organization Name:FUNCTIONAL DIETETICS OF TEXAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:281-615-3708
Mailing Address - Street 1:4630 MAGNOLIA COVE DR APT 1131
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77345-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4630 MAGNOLIA COVE DR APT 1131
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77345-2155
Practice Address - Country:US
Practice Address - Phone:281-615-3708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty