Provider Demographics
NPI:1700435559
Name:ANNIE BURDINE NUTRITION, LLC
Entity Type:Organization
Organization Name:ANNIE BURDINE NUTRITION, LLC
Other - Org Name:DEFORE-BURDINE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BURDINE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:610-573-1365
Mailing Address - Street 1:4264 DAVID DR
Mailing Address - Street 2:
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049-9606
Mailing Address - Country:US
Mailing Address - Phone:610-573-1365
Mailing Address - Fax:
Practice Address - Street 1:184 MAIN ST REAR
Practice Address - Street 2:
Practice Address - City:EMMAUS
Practice Address - State:PA
Practice Address - Zip Code:18049-4015
Practice Address - Country:US
Practice Address - Phone:484-347-9055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-04
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1083966469Medicaid