MEDICARE: ELEVATED SOUL NUTRITION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1659137594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATED SOUL NUTRITION LLC

Provider Business Mailing Address
First Line	:	4332 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-2223
Country	:	US
Telephone Number	:	773-217-8177
Fax Number	:

Provider Business Practice Location Address
First Line	:	4332 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-2223
Country	:	US
Telephone Number	:	773-217-8177
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. SHARONY L BROWN
Credential	:	RD, CDCES
Telephone Number	:	773-217-8177

Provider Enumeration Date	:	02/27/2024
Last Update Date	:	04/06/2024

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