Provider Demographics
NPI:1275958118
Name:NUTRITION BALANCE LLC
Entity Type:Organization
Organization Name:NUTRITION BALANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:CONSIGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:586-778-4877
Mailing Address - Street 1:22811 GREATER MACK AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2021
Mailing Address - Country:US
Mailing Address - Phone:586-778-4877
Mailing Address - Fax:586-778-3004
Practice Address - Street 1:22811 GREATER MACK AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-778-4877
Practice Address - Fax:586-778-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-01
Last Update Date:2014-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI00595403261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center