Provider Demographics
NPI:1093150070
Name:ILIVEWELL NUTRITION THERAPY LLC
Entity Type:Organization
Organization Name:ILIVEWELL NUTRITION THERAPY LLC
Other - Org Name:ILIVEWELL NUTRITION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:PACZOSA
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CEDRD-S
Authorized Official - Phone:512-547-9274
Mailing Address - Street 1:3724 JEFFERSON ST
Mailing Address - Street 2:SUITE 316
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3724 JEFFERSON ST
Practice Address - Street 2:SUITE 316
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6225
Practice Address - Country:US
Practice Address - Phone:512-547-9274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80445133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1700077062Medicaid