1073040465 NPI number — EMPOWER NUTRITION & WELLNESS, LLC

Table of content: TANNER ROBIN BENNETT AUD (NPI 1891361283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073040465 NPI number — EMPOWER NUTRITION & WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMPOWER NUTRITION & WELLNESS, 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:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073040465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8695 RESERVOIR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GERMANSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18053-2724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-866-1115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
187-191 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
EMMAUS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-421-4849
Provider Business Practice Location Address Fax Number:
610-421-4303
Provider Enumeration Date:
05/16/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARNES
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
484-866-1115

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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