Provider Demographics
NPI:1720449184
Name:THRIVE NUTRITION OF CT, LLC
Entity Type:Organization
Organization Name:THRIVE NUTRITION OF CT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUTRITIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:RENA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:914-320-3197
Mailing Address - Street 1:199 ETHAN ALLEN HWY
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-6212
Mailing Address - Country:US
Mailing Address - Phone:914-320-3197
Mailing Address - Fax:
Practice Address - Street 1:199 ETHAN ALLEN HWY
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-6212
Practice Address - Country:US
Practice Address - Phone:914-320-3197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:199 OFFICE SPACE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty