1265778187 NPI number — WHOLESOME NUTRITION, LLC.

Table of content: (NPI 1265778187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265778187 NPI number — WHOLESOME NUTRITION, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHOLESOME NUTRITION, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265778187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 GREENHILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOW GROVE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19090-2812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-576-6305
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 HORSHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSHAM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19044-2140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-675-4535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCKINNEY
Authorized Official First Name:
CASEY
Authorized Official Middle Name:
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
717-576-6305

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  DN003959 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)