Provider Demographics
NPI: | 1821446261 |
---|---|
Name: | JENNIFER MASSON RD LLC |
Entity Type: | Organization |
Organization Name: | JENNIFER MASSON RD LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENNIFER |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MASSO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RD |
Authorized Official - Phone: | 727-455-9066 |
Mailing Address - Street 1: | 2409 HUNTINGTON BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | SAFETY HARBOR |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 34695-5235 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 727-723-9191 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2409 HUNTINGTON BLVD |
Practice Address - Street 2: | |
Practice Address - City: | SAFETY HARBOR |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34695-5235 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-723-9191 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-05-26 |
Last Update Date: | 2016-05-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ND4248 | 133V00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Single Specialty |