Provider Demographics
NPI:1720453814
Name:BORDEAUX NUTRITION LLC
Entity Type:Organization
Organization Name:BORDEAUX NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BORDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDN, CPT
Authorized Official - Phone:860-978-9449
Mailing Address - Street 1:66 CEDAR ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2633
Mailing Address - Country:US
Mailing Address - Phone:860-523-0141
Mailing Address - Fax:860-523-0141
Practice Address - Street 1:66 CEDAR ST
Practice Address - Street 2:305
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2633
Practice Address - Country:US
Practice Address - Phone:860-523-0141
Practice Address - Fax:860-523-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000472133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT695189OtherCONNECTICARE INC.
CT3199218OtherUNITED HEALTHCARE
CT7982509OtherAETNA
CTP3946637OtherOXFORD