Provider Demographics
NPI:1639795727
Name:BAMBOO NUTRITION, LLC
Entity Type:Organization
Organization Name:BAMBOO NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ISABELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN
Authorized Official - Phone:573-343-4017
Mailing Address - Street 1:2012 CHERRY HILL DR STE 202B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5882
Mailing Address - Country:US
Mailing Address - Phone:573-343-4017
Mailing Address - Fax:573-615-4443
Practice Address - Street 1:2012 CHERRY HILL DR STE 202B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5882
Practice Address - Country:US
Practice Address - Phone:573-343-4017
Practice Address - Fax:573-615-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2017032772OtherMISSOURI DIVISION OF PROFESSIONAL REGISTRATION
MO2018035632OtherMISSOURI DIVISION OF PROFESSIONAL REGISTRATION