Healthcare Provider Details

I. General information

NPI: 1285046292
Provider Name (Legal Business Name): DANDELION NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2014
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 7TH AVE SE, SUITE 200 PMB 1962
LACEY WA
98503
US

IV. Provider business mailing address

4405 7TH AVE SE, SUITE 200 PMB 1962
LACEY WA
98503
US

V. Phone/Fax

Practice location:
  • Phone: 206-799-7010
  • Fax: 206-866-0204
Mailing address:
  • Phone: 206-799-1070
  • Fax: 206-866-0204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60202010
License Number StateWA

VIII. Authorized Official

Name: SUNG HYUN MO
Title or Position: CEO
Credential:
Phone: 201-790-6643