Provider Demographics
NPI:1639342710
Name:NUTRITION EXCHANGE, LLC
Entity Type:Organization
Organization Name:NUTRITION EXCHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAMHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:RD,LD,CDE
Authorized Official - Phone:314-583-4525
Mailing Address - Street 1:470 LAKE AVE
Mailing Address - Street 2:UNIT 1 SOUTH
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1100
Mailing Address - Country:US
Mailing Address - Phone:314-583-4525
Mailing Address - Fax:855-568-0468
Practice Address - Street 1:1602 S BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-2208
Practice Address - Country:US
Practice Address - Phone:314-583-4525
Practice Address - Fax:314-583-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025921133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1134315179OtherNPI, INDIVIDUAL
MO000095618Medicare UPIN