Provider Demographics
NPI:1710585245
Name:TIDEWATER NUTRITION LLC
Entity type:Organization
Organization Name:TIDEWATER NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN
Authorized Official - Phone:410-279-0621
Mailing Address - Street 1:600-B ABRUZZI DRIVE
Mailing Address - Street 2:PMB #120
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619
Mailing Address - Country:US
Mailing Address - Phone:410-279-0621
Mailing Address - Fax:
Practice Address - Street 1:120 MCKENNEY LN
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-2139
Practice Address - Country:US
Practice Address - Phone:410-279-0621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty