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General NPI Number Information
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NPI Number | 1235769670
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Entity Type | Organization
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Legal Business Name | MODERN NUTRITION NW LLC
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Dates
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Enumeration Date | 01/24/2020
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Last Update Date | 08/26/2025
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Provider Practice Location Address
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Address Line | 7003 SE YEARLING LN
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City | PORTLAND
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State | OR
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Zip | 97267-1983
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Country | US
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Telephone | 503-650-3801
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Fax | 503-650-7002
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Provider Business Mailing Address
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Address Line | PO BOX 493
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City | CLACKAMAS
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State | OR
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Zip | 97015-0493
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Country | US
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Telephone | 503-650-3801
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Fax | 503-650-7002
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Authorized Official
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Title or Position | REGISTERED DIETITIAN NUTRITIONIST
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Name | MS. KRISTA SUZZANNE SCHAEFER
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Credential | MS RDN LD
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Telephone | 503-313-6461
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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