Healthcare Provider Details

I. General information

NPI: 1497561625
Provider Name (Legal Business Name): EAT HEAL NOURISH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14631 SW MILLIKAN WAY
BEAVERTON OR
97003-2999
US

IV. Provider business mailing address

2850 SW CEDAR HILLS BLVD # 2250
BEAVERTON OR
97005-1354
US

V. Phone/Fax

Practice location:
  • Phone: 503-890-5139
  • Fax:
Mailing address:
  • Phone: 503-890-5139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KOOSJE BOYD
Title or Position: DIETITIAN
Credential:
Phone: 503-890-5139