Provider Demographics
NPI:1407455132
Name:WOTAN NUTRITION LLC
Entity Type:Organization
Organization Name:WOTAN NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOTAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:734-263-7374
Mailing Address - Street 1:900 PATRICIA AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2634
Mailing Address - Country:US
Mailing Address - Phone:734-263-7374
Mailing Address - Fax:
Practice Address - Street 1:900 PATRICIA AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2634
Practice Address - Country:US
Practice Address - Phone:734-263-7374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty