Healthcare Provider Details

I. General information

NPI: 1134513286
Provider Name (Legal Business Name): CORPO SANO NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5331 SW MACADAM AVE SUITE 380
PORTLAND OR
97239-6104
US

IV. Provider business mailing address

1955 SE MORRISON ST APT 208
PORTLAND OR
97214-2782
US

V. Phone/Fax

Practice location:
  • Phone: 503-894-9118
  • Fax:
Mailing address:
  • Phone: 971-270-4977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MS. REBECCA E ROSS
Title or Position: NUTRITIONAL THERAPY PRACTITIONER
Credential: NTP
Phone: 971-270-4977