Provider Demographics
NPI:1568644813
Name:NUTRIWELLNESS4LIFE, LLC
Entity Type:Organization
Organization Name:NUTRIWELLNESS4LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-628-7800
Mailing Address - Street 1:9003 W MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-6988
Mailing Address - Country:US
Mailing Address - Phone:623-628-7800
Mailing Address - Fax:623-388-6234
Practice Address - Street 1:9003 W MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-6988
Practice Address - Country:US
Practice Address - Phone:623-628-7800
Practice Address - Fax:623-388-6234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ914955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ946139Medicaid