Healthcare Provider Details

I. General information

NPI: 1629486964
Provider Name (Legal Business Name): LIVE WELL NUTRITION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 E OMER AVE
MISHAWAKA IN
46545-6345
US

IV. Provider business mailing address

229 E OMER AVE
MISHAWAKA IN
46545-6345
US

V. Phone/Fax

Practice location:
  • Phone: 574-217-8372
  • Fax:
Mailing address:
  • Phone: 574-217-8372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number37001744A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001744A
License Number StateIN

VIII. Authorized Official

Name: MRS. NIKOLE BARRETT
Title or Position: PRESIDENT
Credential: RDN, CD
Phone: 574-217-8372