1003824079 NPI number — INNOVATIVE NUTRITION SOLUTIONS, LLC

Table of content: (NPI 1003824079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003824079 NPI number — INNOVATIVE NUTRITION SOLUTIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE NUTRITION SOLUTIONS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
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NPI Number Information

NPI Number:
1003824079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 DONOFRIO DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53719-2847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-836-3473
Provider Business Mailing Address Fax Number:
608-831-5319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 DONOFRIO DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53719-2847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-836-3473
Provider Business Practice Location Address Fax Number:
608-831-5319
Provider Enumeration Date:
08/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOEHRING
Authorized Official First Name:
KARYN
Authorized Official Middle Name:
EVELYN
Authorized Official Title or Position:
CLINICAL NUTRITION THERAPIST
Authorized Official Telephone Number:
608-836-3473

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  1680-029 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 291U00000X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)