Healthcare Provider Details

I. General information

NPI: 1225207343
Provider Name (Legal Business Name): HEALTHENUTRIFIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 MAIN ST SUITE 100
MENDOTA HEIGHTS MN
55118-3764
US

IV. Provider business mailing address

2282 FIELD STONE DRIVE
MENDOTA HEIGHTS MN
55120-1918
US

V. Phone/Fax

Practice location:
  • Phone: 651-592-7830
  • Fax: 651-405-3850
Mailing address:
  • Phone: 651-592-7830
  • Fax: 651-405-3850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSAN MARIANNE PARKS
Title or Position: CEO/LICENSED RD
Credential: RD, CSSD,LN
Phone: 651-592-7830