Provider Demographics
NPI:1033977418
Name:NUTRAEVOLUTION DIETETICS
Entity Type:Organization
Organization Name:NUTRAEVOLUTION DIETETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVEY-DZIERZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:815-993-1080
Mailing Address - Street 1:2872 ALASKAN WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-5847
Mailing Address - Country:US
Mailing Address - Phone:815-993-1080
Mailing Address - Fax:
Practice Address - Street 1:2872 ALASKAN WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-5847
Practice Address - Country:US
Practice Address - Phone:815-993-1080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center