Healthcare Provider Details

I. General information

NPI: 1770107948
Provider Name (Legal Business Name): BIG HORN NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 N 8TH ST
GREYBULL WY
82426-1504
US

IV. Provider business mailing address

1351 N 8TH ST
GREYBULL WY
82426-1504
US

V. Phone/Fax

Practice location:
  • Phone: 307-679-4639
  • Fax:
Mailing address:
  • Phone: 307-679-4639
  • 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: TENIKA LEIGH EARDLEY
Title or Position: OWNER
Credential: RDN
Phone: 307-679-4639