Provider Demographics
NPI:1235769670
Name:MODERN NUTRITION NW LLC
Entity Type:Organization
Organization Name:MODERN NUTRITION NW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:SUZZANNE
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:MS RDN LD
Authorized Official - Phone:503-313-6461
Mailing Address - Street 1:386 SE REGAN HILL LOOP
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-7400
Mailing Address - Country:US
Mailing Address - Phone:503-313-6461
Mailing Address - Fax:503-650-7002
Practice Address - Street 1:619 MADISON ST STE 102
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2354
Practice Address - Country:US
Practice Address - Phone:503-313-6461
Practice Address - Fax:503-650-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service