Provider Demographics
NPI:1174532519
Name:SOUTHEAST CLINICAL NUTRITION CENTERS, INC.
Entity type:Organization
Organization Name:SOUTHEAST CLINICAL NUTRITION CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:CAPOZZOLI
Authorized Official - Suffix:JR
Authorized Official - Credentials:RD, CSR, LD
Authorized Official - Phone:678-527-0800
Mailing Address - Street 1:5605 GLENRIDGE DR
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1365
Mailing Address - Country:US
Mailing Address - Phone:678-527-0800
Mailing Address - Fax:678-244-9010
Practice Address - Street 1:5605 GLENRIDGE DR
Practice Address - Street 2:SUITE 1050
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1365
Practice Address - Country:US
Practice Address - Phone:678-527-0800
Practice Address - Fax:678-244-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7681Medicare ID - Type Unspecified