Provider Demographics
NPI:1891801791
Name:MEDICAL NUTRITIONAL THERAPISTS, INC.
Entity Type:Organization
Organization Name:MEDICAL NUTRITIONAL THERAPISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLB
Authorized Official - Suffix:
Authorized Official - Credentials:RD LD CDE
Authorized Official - Phone:260-489-9009
Mailing Address - Street 1:4210 FLAGSTAFF CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4417
Mailing Address - Country:US
Mailing Address - Phone:260-489-9009
Mailing Address - Fax:260-489-5057
Practice Address - Street 1:410 FINZER STREET #302
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203
Practice Address - Country:US
Practice Address - Phone:800-245-9009
Practice Address - Fax:260-489-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1619919263OtherNPI
OH1972545507OtherNPI
OH2465612Medicaid
INQ51183Medicare UPIN
IN213960Medicare ID - Type Unspecified
OH2465612Medicaid