1649660549 NPI number — WELLNESS IMPACT NUTRITION, LLC

Table of content: (NPI 1649660549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649660549 NPI number — WELLNESS IMPACT NUTRITION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS IMPACT NUTRITION, 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:
1649660549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3797 N CROFT WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616-2265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-250-5657
Provider Business Mailing Address Fax Number:
208-433-9424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 E WINDING CREEK DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-7060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-250-5657
Provider Business Practice Location Address Fax Number:
208-433-9424
Provider Enumeration Date:
01/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LAJOIE
Authorized Official First Name:
DEENA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/REGISTERED DIETITIAN
Authorized Official Telephone Number:
208-250-5657

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  D-682 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1588936710 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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