Provider Demographics
NPI:1053033365
Name:NUTRIALL WELLNESS CENTER LLC
Entity type:Organization
Organization Name:NUTRIALL WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:XIAOFANG
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-777-4933
Mailing Address - Street 1:3347 213TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1560
Mailing Address - Country:US
Mailing Address - Phone:929-777-4933
Mailing Address - Fax:888-370-1981
Practice Address - Street 1:3347 213TH ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1560
Practice Address - Country:US
Practice Address - Phone:929-777-4933
Practice Address - Fax:888-370-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-13
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16196990555Medicaid
NY1861113441Medicaid