Provider Demographics
NPI:1003399858
Name:ALAVITA PERINATAL NUTRITION ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ALAVITA PERINATAL NUTRITION ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHNENGEL
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:503-407-2549
Mailing Address - Street 1:4611 N KERBY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 SW WOODS ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4739
Practice Address - Country:US
Practice Address - Phone:503-407-2549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10159622133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty