Provider Demographics
NPI:1629546551
Name:SO NUTRITIOUS, LLC
Entity Type:Organization
Organization Name:SO NUTRITIOUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:973-567-3688
Mailing Address - Street 1:68 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7604
Mailing Address - Country:US
Mailing Address - Phone:973-567-3688
Mailing Address - Fax:973-567-3688
Practice Address - Street 1:68 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7604
Practice Address - Country:US
Practice Address - Phone:973-567-3688
Practice Address - Fax:973-567-3688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty