Provider Demographics
NPI:1225207343
Name:HEALTHENUTRIFIT LLC
Entity Type:Organization
Organization Name:HEALTHENUTRIFIT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/LICENSED RD
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIANNE
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CSSD,LN
Authorized Official - Phone:651-592-7830
Mailing Address - Street 1:2282 FIELD STONE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1918
Mailing Address - Country:US
Mailing Address - Phone:651-592-7830
Mailing Address - Fax:651-405-3850
Practice Address - Street 1:750 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55118-3764
Practice Address - Country:US
Practice Address - Phone:651-592-7830
Practice Address - Fax:651-405-3850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN400A2PAOtherBCBS OF MN
MN491211000Medicaid
MN400A2PAOtherBCBS OF MN
MN710000648Medicare PIN