Provider Demographics
NPI:1760038939
Name:NUTRITION CLINIC LLC
Entity Type:Organization
Organization Name:NUTRITION CLINIC LLC
Other - Org Name:THE NUTRITION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHARA
Authorized Official - Middle Name:JOURDAN
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:772-800-3014
Mailing Address - Street 1:402 NW LYNDHURST CT FL 34983
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3440
Mailing Address - Country:US
Mailing Address - Phone:772-878-8227
Mailing Address - Fax:
Practice Address - Street 1:10570 S US HIGHWAY 1 STE 300
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5606
Practice Address - Country:US
Practice Address - Phone:772-878-8227
Practice Address - Fax:772-324-7863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005491300Medicaid