Provider Demographics
NPI:1124397062
Name:MLB NUTRITION & WELLNESS, LLC
Entity Type:Organization
Organization Name:MLB NUTRITION & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOLLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:917-680-2820
Mailing Address - Street 1:5071 W SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4253
Mailing Address - Country:US
Mailing Address - Phone:917-680-2820
Mailing Address - Fax:
Practice Address - Street 1:10101 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2455
Practice Address - Country:US
Practice Address - Phone:917-680-2820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD10144515133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty