Provider Demographics
NPI:1164849832
Name:LIFEQUALITY NUTRITION NETWORK COOPERATIVE INC.
Entity Type:Organization
Organization Name:LIFEQUALITY NUTRITION NETWORK COOPERATIVE INC.
Other - Org Name:LIFEQUALITY, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MISSY
Authorized Official - Last Name:PORTEOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CDE
Authorized Official - Phone:951-317-7657
Mailing Address - Street 1:PO BOX 78653
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92877-0155
Mailing Address - Country:US
Mailing Address - Phone:951-317-7657
Mailing Address - Fax:951-278-8665
Practice Address - Street 1:11801 PIERCE ST SUITE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-4408
Practice Address - Country:US
Practice Address - Phone:951-750-0085
Practice Address - Fax:951-582-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA814382133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04360ZMedicare UPIN