Provider Demographics
NPI:1619683000
Name:INGREDIENTS FOR LIFE LLC
Entity Type:Organization
Organization Name:INGREDIENTS FOR LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTON-SCHNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-582-1212
Mailing Address - Street 1:4745 JAMESTON ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-4222
Mailing Address - Country:US
Mailing Address - Phone:720-582-1212
Mailing Address - Fax:720-405-4268
Practice Address - Street 1:7490 CLUBHOUSE RD STE 105
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3720
Practice Address - Country:US
Practice Address - Phone:720-582-1212
Practice Address - Fax:720-405-4268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty