Nutrisource Nutritional Services

Primary specialty

Registered DietitianTaxonomy code 133V00000X

License

LD002579 Issued in GA

Legal business name

NUTRISOURCE NUTRITIONAL SERVICES

Practice address

3226 Hampton Ave Ste F
Brunswick, GA 31520-4252

Phone

(912) 222-7755

Fax

(912) 264-4071

NPI assigned

May 25, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lauren A Giczewski, R.D., L.D, C.P.T.

Title

Owner

Phone

(912) 222-7755

Specialties & licenses 1

Addresses

Other identifiers 4

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1243209600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1243209600000",
    "number": "1285869974",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "620 SEA ISLAND RD",
            "address_2": "PMB 273",
            "city": "ST SIMONS ISLAND",
            "state": "GA",
            "postal_code": "315221767",
            "telephone_number": "912-222-7755",
            "fax_number": "912-264-4071"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3226 HAMPTON AVE STE F",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315204252",
            "telephone_number": "912-222-7755",
            "fax_number": "912-264-4071"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NUTRISOURCE NUTRITIONAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-25",
        "last_updated": "2009-05-25",
        "status": "A",
        "authorized_official_last_name": "GICZEWSKI",
        "authorized_official_first_name": "LAUREN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "912-222-7755",
        "authorized_official_credential": "R.D., L.D, C.P.T."
    },
    "taxonomies": [
        {
            "code": "133V00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dietitian, Registered",
            "state": "GA",
            "license": "LD002579",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "COMMISSION ON DIETETIC REGISTRATION",
            "identifier": "931505",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AMERICAN DIETETIC ASSOCIATION",
            "identifier": "00931505",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSED DIETITIAN",
            "identifier": "LD002579",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AMERICAN COUNCIL ON EXERCISE PERSONAL TRAINER",
            "identifier": "T118230",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in Brunswick, GA
• Registered Dietitian in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 25, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.