Healthcare Provider Details

I. General information

NPI: 1124368964
Provider Name (Legal Business Name): HOLISTIC ROOTS NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

964 MADISON ST
DENVER CO
80206-4052
US

IV. Provider business mailing address

964 MADISON ST
DENVER CO
80206-4052
US

V. Phone/Fax

Practice location:
  • Phone: 303-818-0494
  • Fax:
Mailing address:
  • Phone: 303-818-0494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: SARA M KOSICK
Title or Position: NUTRITION THERAPIST
Credential: MNT
Phone: 303-818-0494