Healthcare Provider Details

I. General information

NPI: 1124477104
Provider Name (Legal Business Name): BRIGHT SKY NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 07/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3543 S LONE PINE AVE
SPRINGFIELD MO
65804-4854
US

IV. Provider business mailing address

3243 W KATELLA CT
SPRINGFIELD MO
65807-8713
US

V. Phone/Fax

Practice location:
  • Phone: 417-343-8222
  • Fax: 866-542-3416
Mailing address:
  • Phone: 417-343-8222
  • Fax: 866-542-3416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2004029834
License Number StateMO

VIII. Authorized Official

Name: LADONNA MARIE WEBB
Title or Position: OWNER/DIETITIAN
Credential: RD, LD, CDE
Phone: 417-343-8222