Healthcare Provider Details

I. General information

NPI: 1689181976
Provider Name (Legal Business Name): KC NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1693 SW CHANDLER AVE STE 140
BEND OR
97702-3230
US

IV. Provider business mailing address

PO BOX 6232
BEND OR
97708-6232
US

V. Phone/Fax

Practice location:
  • Phone: 541-279-3696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number01013025
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10177506
License Number StateOR

VIII. Authorized Official

Name: KRISTINA COUGHLIN
Title or Position: OWNER
Credential: MS, RDN, LD
Phone: 541-279-3696