Provider Demographics
NPI:1851173561
Name:TETON DIETETICS LLC
Entity Type:Organization
Organization Name:TETON DIETETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXY
Authorized Official - Middle Name:V
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:208-270-4306
Mailing Address - Street 1:680 E 5500 S
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-4613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 E 5500 S
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-4613
Practice Address - Country:US
Practice Address - Phone:208-270-4306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty