Provider Demographics
NPI:1932757085
Name:CUSTOM NUTRITION, LLC
Entity Type:Organization
Organization Name:CUSTOM NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:516-200-4582
Mailing Address - Street 1:390 PLANDOME RD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-1917
Mailing Address - Country:US
Mailing Address - Phone:516-200-4582
Mailing Address - Fax:646-390-4255
Practice Address - Street 1:390 PLANDOME RD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-1917
Practice Address - Country:US
Practice Address - Phone:516-200-4582
Practice Address - Fax:646-390-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty