Provider Demographics
NPI:1790162691
Name:KEYSTONE NUTRITION, LLC
Entity Type:Organization
Organization Name:KEYSTONE NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RDN,LDN
Authorized Official - Phone:478-239-3552
Mailing Address - Street 1:11704 OLDE ENGLISH DR
Mailing Address - Street 2:UNIT E
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3548
Mailing Address - Country:US
Mailing Address - Phone:570-561-7718
Mailing Address - Fax:
Practice Address - Street 1:11710 PLAZA AMERICA DR
Practice Address - Street 2:SUITE 2000
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4742
Practice Address - Country:US
Practice Address - Phone:478-239-3552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005391133V00000X
VA86003242133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1649667528OtherNPI