Provider Demographics
NPI:1669615951
Name:WHOLE NUTRITION SERVICES
Entity type:Organization
Organization Name:WHOLE NUTRITION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDE, CSR, LDN
Authorized Official - Phone:410-877-6077
Mailing Address - Street 1:51 HORSEMAN CT
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4065
Mailing Address - Country:US
Mailing Address - Phone:410-877-6077
Mailing Address - Fax:410-877-6087
Practice Address - Street 1:1011 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-1318
Practice Address - Country:US
Practice Address - Phone:410-877-6077
Practice Address - Fax:410-877-6087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01526133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKBV8REOtherCAREFIRST BLUE CROSS BLUE SHIELD
MDZDMMMedicare PIN
MDKBV8REOtherCAREFIRST BLUE CROSS BLUE SHIELD
MDX71422Medicare UPIN