Provider Demographics
NPI:1457697260
Name:CERTIFIED NUTRITION CONSULTANTS, PLLC
Entity type:Organization
Organization Name:CERTIFIED NUTRITION CONSULTANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BETANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:956-546-4898
Mailing Address - Street 1:14 RIO CT
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-2002
Mailing Address - Country:US
Mailing Address - Phone:956-546-4898
Mailing Address - Fax:956-517-1015
Practice Address - Street 1:855 W PRICE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-8742
Practice Address - Country:US
Practice Address - Phone:956-546-4898
Practice Address - Fax:956-517-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05843133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150179305Medicaid