MEDICARE: KC 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	133N00000X	Nutritionist	01013025	CA
2	133V00000X	Registered Dietitian	LD-D-10177506	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1801333935	OTHER		DEPARTMENT HEALTH AND HUMAN SERVICES

General Provider Information

NPI Number	:	1689181976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KC NUTRITION, LLC

Provider Business Mailing Address
First Line	:	PO BOX 6232
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97708-6232
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1693 SW CHANDLER AVE STE 140
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3230
Country	:	US
Telephone Number	:	541-279-3696
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTINA COUGHLIN
Credential	:	MS, RDN, LD
Telephone Number	:	541-279-3696

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	01/08/2018

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Directions to “KC NUTRITION, LLC ” Practice Location

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