Provider Demographics
NPI:1851785380
Name:ELIZABETH MADISON NUTRITION, PLLC
Entity Type:Organization
Organization Name:ELIZABETH MADISON NUTRITION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:855-958-9958
Mailing Address - Street 1:22919 MERRICK BLVD
Mailing Address - Street 2:#226
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2108
Mailing Address - Country:US
Mailing Address - Phone:718-276-6037
Mailing Address - Fax:855-947-3783
Practice Address - Street 1:13333 BROOKVILLE BOULEVARD
Practice Address - Street 2:SUITE 229C
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422
Practice Address - Country:US
Practice Address - Phone:855-958-9958
Practice Address - Fax:855-947-3783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00800548133V00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty