Provider Demographics
NPI:1871600700
Name:MEDICAL NUTRITION THERAPY OF FLORIDA, INC.
Entity type:Organization
Organization Name:MEDICAL NUTRITION THERAPY OF FLORIDA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:TRCALEK
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN
Authorized Official - Phone:904-724-2043
Mailing Address - Street 1:4237 SALISBURY RD N
Mailing Address - Street 2:STE 314
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8029
Mailing Address - Country:US
Mailing Address - Phone:904-724-2043
Mailing Address - Fax:904-724-2013
Practice Address - Street 1:4237 SALISBURY RD N
Practice Address - Street 2:STE 314
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8029
Practice Address - Country:US
Practice Address - Phone:904-724-2043
Practice Address - Fax:904-724-2013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL165968OtherHEALTHEASE/WELLCARE
FL165968OtherHEALTHEASE/WELLCARE