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General NPI Number Information
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NPI Number | 1467075663
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Entity Type | Organization
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Legal Business Name | PROACTIVE NUTRITION & WELLNESS INC
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Dates
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Enumeration Date | 05/21/2020
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Last Update Date | 05/21/2020
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Provider Practice Location Address
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Address Line | 1455 LAUREL AVE
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City | COOS BAY
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State | OR
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Zip | 97420-2167
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Country | US
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Telephone | 727-409-0016
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Fax |
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Provider Business Mailing Address
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Address Line | 1455 LAUREL AVE
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City | COOS BAY
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State | OR
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Zip | 97420-2167
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Country | US
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Telephone | 727-409-0016
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ANDREW WINQUIST
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Credential | RD/LDN
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Telephone | 727-409-0016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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