Provider Demographics
NPI:1851567705
Name:FOUR COUNTY NUTRITION, INC
Entity Type:Organization
Organization Name:FOUR COUNTY NUTRITION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:STAMATES
Authorized Official - Last Name:ROERTY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:240-215-5084
Mailing Address - Street 1:1104 VILLAGE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5378
Mailing Address - Country:US
Mailing Address - Phone:240-215-5084
Mailing Address - Fax:
Practice Address - Street 1:1104 VILLAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5378
Practice Address - Country:US
Practice Address - Phone:240-215-5084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01409133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty