Provider Demographics
NPI:1003824079
Name:INNOVATIVE NUTRITION SOLUTIONS, LLC
Entity Type:Organization
Organization Name:INNOVATIVE NUTRITION SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL NUTRITION THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KARYN
Authorized Official - Middle Name:EVELYN
Authorized Official - Last Name:MOEHRING
Authorized Official - Suffix:
Authorized Official - Credentials:MA, RD, CD
Authorized Official - Phone:608-836-3473
Mailing Address - Street 1:414 DONOFRIO DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2847
Mailing Address - Country:US
Mailing Address - Phone:608-836-3473
Mailing Address - Fax:608-831-5319
Practice Address - Street 1:414 DONOFRIO DR
Practice Address - Street 2:SUITE 120
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2847
Practice Address - Country:US
Practice Address - Phone:608-836-3473
Practice Address - Fax:608-831-5319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1680-029133V00000X
WI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Not Answered291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003824269Medicare ID - Type UnspecifiedDIETITIAN