Provider Demographics
NPI:1821438078
Name:PERSONALIZED NUTRITION INC
Entity Type:Organization
Organization Name:PERSONALIZED NUTRITION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RD,CDE
Authorized Official - Phone:239-734-2600
Mailing Address - Street 1:590 STARBOARD DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-4144
Mailing Address - Country:US
Mailing Address - Phone:239-734-2600
Mailing Address - Fax:
Practice Address - Street 1:661 GOODLETTE RD N
Practice Address - Street 2:SUITE 104
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5609
Practice Address - Country:US
Practice Address - Phone:239-649-4565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND332133V00000X
FLND429133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCJ889Medicare UPIN
FLE8429Medicare UPIN