MEDICARE: STRATEGIC NUTRITION

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	LD-D-000446	OR

General Provider Information

NPI Number	:	1679823108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STRATEGIC NUTRITION

Provider Business Mailing Address
First Line	:	5021 TUALATA LN
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-7116
Country	:	US
Telephone Number	:	503-974-6454
Fax Number	:

Provider Business Practice Location Address
First Line	:	5021 TUALATA LN
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-7116
Country	:	US
Telephone Number	:	503-974-6454
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	NICOLE L STREALY
Credential	:	RD, LD
Telephone Number	:	503-974-6454

Provider Enumeration Date	:	09/12/2012
Last Update Date	:	09/12/2012

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