Healthcare Provider Details

I. General information

NPI: 1124397062
Provider Name (Legal Business Name): MLB NUTRITION & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 SE MAIN ST
PORTLAND OR
97216-2455
US

IV. Provider business mailing address

5071 W SUNSET DR
LAKE OSWEGO OR
97035-4253
US

V. Phone/Fax

Practice location:
  • Phone: 917-680-2820
  • Fax:
Mailing address:
  • Phone: 917-680-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLDD10144515
License Number StateOR

VIII. Authorized Official

Name: MS. MELISSA LYNN BOLLMAN
Title or Position: PRESIDENT
Credential: M.S., R.D.
Phone: 917-680-2820