MEDICARE: PARTNERS IN 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	261QH0100X	Health Service Clinic/Center	R708546	CO

General Provider Information

NPI Number	:	1710350012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARTNERS IN NUTRITION, LLC

Provider Business Mailing Address
First Line	:	1907 HILLROSE DR
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-3438
Country	:	US
Telephone Number	:	970-622-9997
Fax Number	:	970-667-8383

Provider Business Practice Location Address
First Line	:	1101 OAKRIDGE DR
Second Line	:	SUITE B
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-5528
Country	:	US
Telephone Number	:	970-622-9997
Fax Number	:	970-667-8383

Authorized Official
Title or Position	:	OWNER
Name	:	MS. JACQUELYN JO NIELSEN
Credential	:	MS, RD, CDE
Telephone Number	:	970-622-9997

Provider Enumeration Date	:	11/09/2015
Last Update Date	:	11/09/2015

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