Provider Demographics
NPI:1912163783
Name:PRODIGY NUTRITIONAL CONSULTING, LLC
Entity Type:Organization
Organization Name:PRODIGY NUTRITIONAL CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANTELLE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:225-247-0074
Mailing Address - Street 1:5635 MAIN ST
Mailing Address - Street 2:STE A 238
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5635 MAIN ST
Practice Address - Street 2:STE A 238
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4083
Practice Address - Country:US
Practice Address - Phone:225-247-0074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2070133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty