Provider Demographics
NPI:1013681063
Name:NAZ MADURO NUTRITION LLC
Entity type:Organization
Organization Name:NAZ MADURO NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAZIRBER
Authorized Official - Middle Name:D
Authorized Official - Last Name:MADURO
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CDN, CDCES
Authorized Official - Phone:347-898-6680
Mailing Address - Street 1:11835 QUEENS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7211
Mailing Address - Country:US
Mailing Address - Phone:929-307-0050
Mailing Address - Fax:
Practice Address - Street 1:11835 QUEENS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7211
Practice Address - Country:US
Practice Address - Phone:929-307-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-03
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1306391586OtherNAZIRBER MADURO INDIVIDUAL NPI
NY03813283Medicaid