Provider Demographics
NPI:1679891279
Name:ACTIVE NUTRITION
Entity type:Organization
Organization Name:ACTIVE NUTRITION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD CDN
Authorized Official - Phone:716-608-7697
Mailing Address - Street 1:2238 OLD UNION RD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-2728
Mailing Address - Country:US
Mailing Address - Phone:716-608-7697
Mailing Address - Fax:716-668-2671
Practice Address - Street 1:2238 OLD UNION RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-2728
Practice Address - Country:US
Practice Address - Phone:716-608-7697
Practice Address - Fax:716-668-2671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000926855133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0206OtherHEALTHNOW UMD