Provider Demographics
NPI:1104043553
Name:ESSENTIAL NUTRITION, INC
Entity Type:Organization
Organization Name:ESSENTIAL NUTRITION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HIGH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:303-725-4343
Mailing Address - Street 1:4730 WALNUT ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2558
Mailing Address - Country:US
Mailing Address - Phone:303-725-4343
Mailing Address - Fax:303-546-0047
Practice Address - Street 1:4730 WALNUT ST
Practice Address - Street 2:SUITE 212
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2558
Practice Address - Country:US
Practice Address - Phone:303-725-4343
Practice Address - Fax:303-546-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO838488261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center