Provider Demographics
NPI:1639739816
Name:LIFETIME NUTRITION AND WELLNESS LLC
Entity Type:Organization
Organization Name:LIFETIME NUTRITION AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GLASER
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:402-802-2639
Mailing Address - Street 1:PO BOX 820472
Mailing Address - Street 2:
Mailing Address - City:N RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-0472
Mailing Address - Country:US
Mailing Address - Phone:817-718-9412
Mailing Address - Fax:682-200-3258
Practice Address - Street 1:5592 DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:N RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-5202
Practice Address - Country:US
Practice Address - Phone:817-718-9412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-19
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty