Provider Demographics
NPI:1659137594
Name:ELEVATED SOUL NUTRITION LLC
Entity Type:Organization
Organization Name:ELEVATED SOUL NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDCES
Authorized Official - Phone:773-217-8177
Mailing Address - Street 1:4332 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2223
Mailing Address - Country:US
Mailing Address - Phone:773-217-8177
Mailing Address - Fax:
Practice Address - Street 1:4332 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2223
Practice Address - Country:US
Practice Address - Phone:773-217-8177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-27
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty