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General NPI Number Information
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NPI Number | 1417442120
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Entity Type | Organization
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Legal Business Name | MOUNTAIN HOME NUTRITION SERVICES LLC
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Dates
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Enumeration Date | 06/25/2018
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Last Update Date | 09/11/2018
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Provider Practice Location Address
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Address Line | 285 E 4TH N
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647
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Country | US
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Telephone | 208-590-0858
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Fax |
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Provider Business Mailing Address
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Address Line | 285 E 4TH N
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-2716
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Country | US
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Telephone | 208-590-0858
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LAURA J MOULTON
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Credential | RD,LD
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Telephone | 208-590-9348
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | D-039
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License Number State | ID
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