Provider Demographics
NPI:1174838304
Name:NUTRITION SENSE 4 LIFE
Entity Type:Organization
Organization Name:NUTRITION SENSE 4 LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:269-680-7041
Mailing Address - Street 1:12836 CUTLER COVE ST
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-8862
Mailing Address - Country:US
Mailing Address - Phone:269-680-7041
Mailing Address - Fax:
Practice Address - Street 1:12836 CUTLER COVE ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-8862
Practice Address - Country:US
Practice Address - Phone:269-680-7041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1000109133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174838304Medicaid
MI1174838304Medicaid