Provider Demographics
NPI:1609164995
Name:ROWANSOM NUTRITIONAL THERAPY
Entity type:Organization
Organization Name:ROWANSOM NUTRITIONAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM CHIEF FINANCIAL OFFICIER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-770-5772
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08099-0635
Mailing Address - Country:US
Mailing Address - Phone:856-566-6706
Mailing Address - Fax:856-566-2797
Practice Address - Street 1:42 E LAUREL RD
Practice Address - Street 2:UDP#2500
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-2700
Practice Address - Fax:856-566-6873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
228721Medicare PIN