Provider Demographics
NPI:1134513286
Name:CORPO SANO NUTRITION LLC
Entity Type:Organization
Organization Name:CORPO SANO NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUTRITIONAL THERAPY PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:NTP
Authorized Official - Phone:971-270-4977
Mailing Address - Street 1:1955 SE MORRISON ST
Mailing Address - Street 2:APT 208
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2782
Mailing Address - Country:US
Mailing Address - Phone:971-270-4977
Mailing Address - Fax:
Practice Address - Street 1:5331 SW MACADAM AVE
Practice Address - Street 2:SUITE 380
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6104
Practice Address - Country:US
Practice Address - Phone:503-894-9118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty