Provider Demographics
NPI:1548517626
Name:KSRD NUTRITION LLC
Entity type:Organization
Organization Name:KSRD NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:STELMACH
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:973-518-2674
Mailing Address - Street 1:600 VALLEY RD
Mailing Address - Street 2:SUITE LLR1
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3535
Mailing Address - Country:US
Mailing Address - Phone:973-518-2674
Mailing Address - Fax:
Practice Address - Street 1:600 VALLEY RD
Practice Address - Street 2:SUITE LLR1
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3535
Practice Address - Country:US
Practice Address - Phone:973-518-2674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ962920133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1699002113OtherNPI, INDIVIDUAL
NJ12413713OtherCAQH