Provider Demographics
NPI:1629486964
Name:LIVE WELL NUTRITION, INC.
Entity Type:Organization
Organization Name:LIVE WELL NUTRITION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CD
Authorized Official - Phone:574-217-8372
Mailing Address - Street 1:229 E OMER AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-6345
Mailing Address - Country:US
Mailing Address - Phone:574-217-8372
Mailing Address - Fax:
Practice Address - Street 1:229 E OMER AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-6345
Practice Address - Country:US
Practice Address - Phone:574-217-8372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001744A133V00000X, 133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Single Specialty