# MODERN MEDICAL NUTRITION THERAPY, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1699217885
- **Authorized official:** MR. RAPHAEL OVONLEN MPH, MS, RDN, LMNT, (CEO)
- **Authorized official phone:** (402) 618-0209

## Contact information

- **Practice address:** 530 S 13TH ST, STE 100, LINCOLN, NE 68508-2710
- **Practice address phone:** (402) 618-0209
- **Practice address fax:** (402) 905-0321
- **Mailing address:** 6554 S 117TH ST, OMAHA, NE 68137-5726
- **Mailing address phone:** (402) 618-0209
- **Mailing address fax:** (402) 905-0321

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 133VN1006X | Metabolic Nutrition Registered Dietitian | 752 | NE | Yes |

## Other

- **Enumeration date:** 11/05/2016
- **Last updated:** 11/05/2016