Provider Demographics
NPI:1528639978
Name:KSSENTIAL NUTRITION LLC
Entity type:Organization
Organization Name:KSSENTIAL NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:KANWAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSUR
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CNS,LDN,MBBS
Authorized Official - Phone:240-460-8290
Mailing Address - Street 1:2802 TYBURN OAKS CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-7271
Mailing Address - Country:US
Mailing Address - Phone:240-460-8290
Mailing Address - Fax:
Practice Address - Street 1:2802 TYBURN OAKS CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-7271
Practice Address - Country:US
Practice Address - Phone:240-460-8290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty