Provider Demographics
NPI:1619309283
Name:BECOME NOURISHED BY NATURE
Entity Type:Organization
Organization Name:BECOME NOURISHED BY NATURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-750-2811
Mailing Address - Street 1:4760 S HIGHLAND DR # 149
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5149
Mailing Address - Country:US
Mailing Address - Phone:801-750-2811
Mailing Address - Fax:
Practice Address - Street 1:4646 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5270
Practice Address - Country:US
Practice Address - Phone:801-750-2811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53765394701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty