Provider Demographics
NPI:1780298257
Name:LAURA YOUR DIETITIAN LLC
Entity type:Organization
Organization Name:LAURA YOUR DIETITIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRESTA
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:215-779-9511
Mailing Address - Street 1:4 CRICKET CIRCLE
Mailing Address - Street 2:
Mailing Address - City:HORSHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19044
Mailing Address - Country:US
Mailing Address - Phone:215-779-9511
Mailing Address - Fax:
Practice Address - Street 1:1030 N 2ND ST UNIT 303
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-1595
Practice Address - Country:US
Practice Address - Phone:215-779-9511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty