1275862807 NPI number — THRIVE FAMILY NUTRITION SERVICES, LLC

Table of content: (NPI 1275862807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275862807 NPI number — THRIVE FAMILY NUTRITION SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIVE FAMILY NUTRITION SERVICES, 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:
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:
1275862807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
374 S 1230 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPANISH FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84660-5531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-857-7440
Provider Business Mailing Address Fax Number:
866-340-7791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 E 100 N
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
PAYSON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84651-1635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-857-7440
Provider Business Practice Location Address Fax Number:
866-340-7791
Provider Enumeration Date:
12/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PACKER
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
REGISTERED DIETITIAN/OWNER
Authorized Official Telephone Number:
801-857-7440

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  6324049-4901 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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