Provider Demographics
NPI:1871504142
Name:ONE SOURCE NUTRITION, LLC
Entity Type:Organization
Organization Name:ONE SOURCE NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:MPH, RD, CDN
Authorized Official - Phone:917-697-7614
Mailing Address - Street 1:668 GLENBROOK RD APT 33
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906-1434
Mailing Address - Country:US
Mailing Address - Phone:917-697-7614
Mailing Address - Fax:
Practice Address - Street 1:301 MERRITT 7
Practice Address - Street 2:WELLNESS CENTER
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1070
Practice Address - Country:US
Practice Address - Phone:203-604-0202
Practice Address - Fax:203-604-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000764261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service