Provider Demographics
NPI:1679389597
Name:MOULTRY, IRVIN (RDN)
Entity type:Individual
Prefix:
First Name:IRVIN
Middle Name:
Last Name:MOULTRY
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14159 E BELLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1170
Mailing Address - Country:US
Mailing Address - Phone:719-482-0392
Mailing Address - Fax:
Practice Address - Street 1:14159 E BELLEWOOD DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1170
Practice Address - Country:US
Practice Address - Phone:719-482-0392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics