Provider Demographics
NPI:1003370115
Name:SUMMIT PERFORMANCE NUTRITION LLC
Entity Type:Organization
Organization Name:SUMMIT PERFORMANCE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE-LIESTER
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:719-684-5754
Mailing Address - Street 1:6156 ROCKVILLE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3806
Mailing Address - Country:US
Mailing Address - Phone:719-684-5754
Mailing Address - Fax:
Practice Address - Street 1:6156 ROCKVILLE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3806
Practice Address - Country:US
Practice Address - Phone:719-684-5754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty