Provider Demographics
NPI:1891922597
Name:NUTRITION THERAPY CLINIC
Entity Type:Organization
Organization Name:NUTRITION THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIETITIAN/DIABETES EDUCATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARA
Authorized Official - Middle Name:VELKERS
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CDE,
Authorized Official - Phone:937-435-4355
Mailing Address - Street 1:1400 HERITAGE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3305
Mailing Address - Country:US
Mailing Address - Phone:937-435-4355
Mailing Address - Fax:937-434-0102
Practice Address - Street 1:5563 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2225
Practice Address - Country:US
Practice Address - Phone:937-435-4355
Practice Address - Fax:937-434-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty