Provider Demographics
NPI:1811229487
Name:NUTRITIONMAGIC, INC.
Entity Type:Organization
Organization Name:NUTRITIONMAGIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:CAROLINE
Authorized Official - Last Name:LAFONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:MA,RD,LD
Authorized Official - Phone:706-579-1992
Mailing Address - Street 1:11563 BIG CANOE
Mailing Address - Street 2:4054 SOARING HAWK CIRCLE
Mailing Address - City:BIG CANOE
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5115
Mailing Address - Country:US
Mailing Address - Phone:706-579-1992
Mailing Address - Fax:866-900-4295
Practice Address - Street 1:11563 BIG CANOE
Practice Address - Street 2:4054 SOARING HAWK CIRCLE
Practice Address - City:BIG CANOE
Practice Address - State:GA
Practice Address - Zip Code:30143-5115
Practice Address - Country:US
Practice Address - Phone:706-579-1992
Practice Address - Fax:866-900-4295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000961133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty