=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851909857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 100 PERCENT NUTRITION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2020
-----------------------------------------------------
Last Update Date | 07/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8425 WALDRIP RD
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30506-5774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-815-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8425 WALDRIP RD
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30506-5774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-815-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATIE POTTS-CARR
-----------------------------------------------------
Credential | RD
-----------------------------------------------------
Telephone | 678-815-4551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------