Provider Demographics
NPI:1336865716
Name:BODY SCULPT AND NUTRITION CONSULTING, LLC
Entity Type:Organization
Organization Name:BODY SCULPT AND NUTRITION CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDN
Authorized Official - Prefix:
Authorized Official - First Name:NORAH
Authorized Official - Middle Name:ALILA
Authorized Official - Last Name:OTIENO-WASONGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-371-7297
Mailing Address - Street 1:500 N MAIN STREET
Mailing Address - Street 2:UNIT D, SUITE #202
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-2020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 N MAIN STREET
Practice Address - Street 2:UNIT D, SUITE #202
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2020
Practice Address - Country:US
Practice Address - Phone:781-728-5783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5534OtherLICENSE