Provider Demographics
NPI:1003256181
Name:NUTRIWELL LLC
Entity Type:Organization
Organization Name:NUTRIWELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:N
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:267-760-7770
Mailing Address - Street 1:4055 RIDGE AVE
Mailing Address - Street 2:3608
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1576
Mailing Address - Country:US
Mailing Address - Phone:267-760-7778
Mailing Address - Fax:
Practice Address - Street 1:4055 RIDGE AVE
Practice Address - Street 2:3608
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1576
Practice Address - Country:US
Practice Address - Phone:267-760-7778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004001133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty