Provider Demographics
NPI:1124302302
Name:NUTRITION COUNSELING CLINIC
Entity type:Organization
Organization Name:NUTRITION COUNSELING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-271-2113
Mailing Address - Street 1:1200 N STONEWALL AVE
Mailing Address - Street 2:AHB 3057
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1215
Mailing Address - Country:US
Mailing Address - Phone:405-271-2113
Mailing Address - Fax:405-271-1560
Practice Address - Street 1:1200 N STONEWALL AVE
Practice Address - Street 2:AHB 1082
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1215
Practice Address - Country:US
Practice Address - Phone:405-271-2866
Practice Address - Fax:405-271-3360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty