Healthcare Provider Details

I. General information

NPI: 1811518103
Provider Name (Legal Business Name): BLUE TREE NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E PINE ST
ZIONSVILLE IN
46077-1529
US

IV. Provider business mailing address

PO BOX 73
CARMEL IN
46082-0073
US

V. Phone/Fax

Practice location:
  • Phone: 410-963-4782
  • Fax: 317-671-7633
Mailing address:
  • Phone: 410-963-4782
  • Fax: 317-671-7633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MRS. VALERIE LYNN POLLEY
Title or Position: REGISTERED DIETITIAN
Credential: RD
Phone: 410-963-4782