Provider Demographics
NPI:1639631195
Name:LIBERATED NUTRITION, LLC.
Entity Type:Organization
Organization Name:LIBERATED NUTRITION, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:860-818-3865
Mailing Address - Street 1:100 LANDSDOWNE ST APT 1002
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4225
Mailing Address - Country:US
Mailing Address - Phone:860-818-3865
Mailing Address - Fax:
Practice Address - Street 1:399 BOYLSTON ST STE 900
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3305
Practice Address - Country:US
Practice Address - Phone:860-818-3865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty