Healthcare Provider Details

I. General information

NPI: 1740605088
Provider Name (Legal Business Name): TAILORED NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 S MAIN ST
SHERIDAN WY
82801-4221
US

IV. Provider business mailing address

37 S MAIN ST
SHERIDAN WY
82801-4221
US

V. Phone/Fax

Practice location:
  • Phone: 307-752-8213
  • Fax: 307-675-1866
Mailing address:
  • Phone: 307-752-8213
  • Fax: 307-675-1866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number81
License Number StateWY

VIII. Authorized Official

Name: MRS. GEORGIA FLETCHER BOLEY
Title or Position: REGISTERED DIETITIAN
Credential: MS,RD,LD,CSO
Phone: 307-752-8213