Provider Demographics
NPI:1700181914
Name:NUTRITION CENTER FOR DISEASE AND WEIGHT MANAGEMENT
Entity Type:Organization
Organization Name:NUTRITION CENTER FOR DISEASE AND WEIGHT MANAGEMENT
Other - Org Name:NUTRITION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAO
Authorized Official - Middle Name:
Authorized Official - Last Name:IVATURI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD CNS
Authorized Official - Phone:812-299-2999
Mailing Address - Street 1:PO BOX 6037
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-6037
Mailing Address - Country:US
Mailing Address - Phone:812-235-5555
Mailing Address - Fax:812-234-2700
Practice Address - Street 1:4779 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4559
Practice Address - Country:US
Practice Address - Phone:812-235-5555
Practice Address - Fax:812-234-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00055133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherPRIVATE INSURANCE COMPANIES
IN147180FFFMedicare PIN