Provider Demographics
NPI:1437904141
Name:IDENTITY NUTRITION, LLC
Entity Type:Organization
Organization Name:IDENTITY NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BROCHET
Authorized Official - Suffix:
Authorized Official - Credentials:MA, RD, LDN, CDCES
Authorized Official - Phone:610-466-5649
Mailing Address - Street 1:1284 STERNER MILL RD
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-7702
Mailing Address - Country:US
Mailing Address - Phone:610-466-5649
Mailing Address - Fax:
Practice Address - Street 1:1284 STERNER MILL RD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-7702
Practice Address - Country:US
Practice Address - Phone:610-466-5649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty