Provider Demographics
NPI:1043693641
Name:ROCKET NUTRITION, LLC
Entity Type:Organization
Organization Name:ROCKET NUTRITION, LLC
Other - Org Name:ROCKET NUTRITION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:REIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDDUTH
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CD
Authorized Official - Phone:774-768-0531
Mailing Address - Street 1:4110 STONE WAY N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8000
Mailing Address - Country:US
Mailing Address - Phone:774-768-0531
Mailing Address - Fax:
Practice Address - Street 1:4110 STONE WAY N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8000
Practice Address - Country:US
Practice Address - Phone:774-768-0531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60569923133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty