Provider Demographics
NPI:1942787122
Name:DESERT DIETITIANS LLC
Entity Type:Organization
Organization Name:DESERT DIETITIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:INGENITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-352-3063
Mailing Address - Street 1:7073 LEADVILLE PEAK AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89179-1503
Mailing Address - Country:US
Mailing Address - Phone:608-206-4837
Mailing Address - Fax:
Practice Address - Street 1:2470 W HORIZON RIDGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2733
Practice Address - Country:US
Practice Address - Phone:608-206-4837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty