Provider Demographics
NPI:1902299639
Name:NUTRITION SPECIALISTS OF NORTHEASTERN OKLAHOMA
Entity Type:Organization
Organization Name:NUTRITION SPECIALISTS OF NORTHEASTERN OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:918-272-4207
Mailing Address - Street 1:10105 N BRIDGEWATER CIR
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-7727
Mailing Address - Country:US
Mailing Address - Phone:918-272-4207
Mailing Address - Fax:866-296-1005
Practice Address - Street 1:10105 N BRIDGEWATER CIR
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-7727
Practice Address - Country:US
Practice Address - Phone:918-272-4207
Practice Address - Fax:866-296-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1488133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty