1811518103 NPI number — BLUE TREE NUTRITION

Table of content: (NPI 1811518103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811518103 NPI number — BLUE TREE NUTRITION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE TREE NUTRITION
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:
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:
1811518103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 73
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46082-0073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-963-4782
Provider Business Mailing Address Fax Number:
317-671-7633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 E PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZIONSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46077-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-963-4782
Provider Business Practice Location Address Fax Number:
317-671-7633
Provider Enumeration Date:
04/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
POLLEY
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
REGISTERED DIETITIAN
Authorized Official Telephone Number:
410-963-4782

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1619321973 . This is a "TYPE 1" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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