Provider Demographics
NPI:1598409468
Name:WELL NOURISHED LLC
Entity Type:Organization
Organization Name:WELL NOURISHED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:
Authorized Official - First Name:HOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C, CAQ-PSYCH
Authorized Official - Phone:720-241-2489
Mailing Address - Street 1:8087 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-6012
Mailing Address - Country:US
Mailing Address - Phone:720-241-2489
Mailing Address - Fax:
Practice Address - Street 1:12157 W CEDAR DR STE 200
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2105
Practice Address - Country:US
Practice Address - Phone:720-513-1215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health