Provider Demographics
NPI:1700123064
Name:ELLAD NUTRITION CONSULTING, LLC
Entity Type:Organization
Organization Name:ELLAD NUTRITION CONSULTING, LLC
Other - Org Name:ELLAD PREVENTATIVE HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, ANP,CNS,MSN, MED
Authorized Official - Phone:804-616-4378
Mailing Address - Street 1:PO BOX 2947
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-9118
Mailing Address - Country:US
Mailing Address - Phone:804-616-4378
Mailing Address - Fax:804-616-4378
Practice Address - Street 1:9401 COURTHOUSE RD STE 202
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6687
Practice Address - Country:US
Practice Address - Phone:804-616-4378
Practice Address - Fax:804-451-4586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV8524AOtherMEDICARE PTAN
VAQ40608AOtherMEDICARE PTAN
VAQ40608AOtherMEDICARE PTAN