Basic Information
| Provider Information | |||||||||
| NPI: | 1609164995 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROWANSOM NUTRITIONAL THERAPY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UMDNJ-SOM NUTRITIONAL THERAPY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | BELLMAWR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080990635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666706 | ||||||||
| FaxNumber: | 8565662797 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 E LAUREL RD | ||||||||
| Address2: | UDP#2500 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565662700 | ||||||||
| FaxNumber: | 8565666873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2011 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | RIEKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF FINANCIAL OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 8567705772 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.