Provider Demographics
NPI:1255767745
Name:COUNSELING AND NUTRITION CENTER 360, LLC
Entity type:Organization
Organization Name:COUNSELING AND NUTRITION CENTER 360, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PEARL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:781-674-1189
Mailing Address - Street 1:33 BEDFORD ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-4319
Mailing Address - Country:US
Mailing Address - Phone:781-674-1189
Mailing Address - Fax:781-863-2646
Practice Address - Street 1:373 HIGHLAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2553
Practice Address - Country:US
Practice Address - Phone:781-674-1189
Practice Address - Fax:781-863-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1024133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty