Provider Demographics
NPI:1386029858
Name:SAGE WISDOM NUTRITION LLC
Entity Type:Organization
Organization Name:SAGE WISDOM NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TASLER
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:253-951-4820
Mailing Address - Street 1:PO BOX 97115
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0115
Mailing Address - Country:US
Mailing Address - Phone:253-588-7911
Mailing Address - Fax:253-365-6299
Practice Address - Street 1:1019 PACIFIC AVE
Practice Address - Street 2:SUITE 801
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4443
Practice Address - Country:US
Practice Address - Phone:253-254-6945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60417979133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI60417979OtherLICENSE NO