Organization
NUTRISOURCE NUTRITIONAL SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LAUREN A GICZEWSKI R.D., L.D, C.P.T. (OWNER)
(912) 222-7755
Entity
Organization
Contact information
Practice address
3226 HAMPTON AVE STE F, BRUNSWICK, GA 31520-4252
(912) 222-7755
(912) 264-4071
Mailing address
620 SEA ISLAND RD, PMB 273, ST SIMONS ISLAND, GA 31522-1767
(912) 222-7755
(912) 264-4071
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
LD002579
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00931505
AMERICAN DIETETIC ASSOCIATION
—
01
—
931505
COMMISSION ON DIETETIC REGISTRATION
—
01
—
LD002579
LICENSED DIETITIAN
GA
01
—
T118230
AMERICAN COUNCIL ON EXERCISE PERSONAL TRAINER
—
Enumeration date
05/25/2009
Last updated
05/25/2009
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