Healthcare Provider Details

I. General information

NPI: 1548221682
Provider Name (Legal Business Name): LIVE NUTRITION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 WAMPUM DR
BREWSTER MA
02631-1956
US

IV. Provider business mailing address

26 WAMPUM DR PO BOX 1709
BREWSTER MA
02631-1956
US

V. Phone/Fax

Practice location:
  • Phone: 508-896-9080
  • Fax: 508-896-3399
Mailing address:
  • Phone: 508-896-9080
  • Fax: 508-896-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberNU445
License Number StateMA

VIII. Authorized Official

Name: MS. MARGARET DAVIS
Title or Position: NUTRITIONISST OWNER
Credential: MS,RD,LDN,FADA,CDE
Phone: 508-896-9080