Provider Demographics
NPI:1356977854
Name:MEDICAL NUTRITION SPECIALISTS LLC
Entity type:Organization
Organization Name:MEDICAL NUTRITION SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-447-1650
Mailing Address - Street 1:144 N 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 N 8TH AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-1728
Practice Address - Country:US
Practice Address - Phone:720-447-1650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty