Provider Demographics
NPI:1003678467
Name:NORTH STAR NUTRITION COUNSELING , LLC
Entity Type:Organization
Organization Name:NORTH STAR NUTRITION COUNSELING , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATAVULI
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED DIETITIAN
Authorized Official - Phone:812-318-0445
Mailing Address - Street 1:3403 N JINNI LYNN CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-1181
Mailing Address - Country:US
Mailing Address - Phone:812-318-0445
Mailing Address - Fax:
Practice Address - Street 1:101 W KIRKWOOD AVE STE 213
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-6134
Practice Address - Country:US
Practice Address - Phone:123-180-4458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty