Provider Demographics
NPI:1659741726
Name:THE FARE SQUARE, LLC
Entity Type:Organization
Organization Name:THE FARE SQUARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN
Authorized Official - Phone:210-289-5859
Mailing Address - Street 1:373 MARTIN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-4108
Mailing Address - Country:US
Mailing Address - Phone:210-289-5858
Mailing Address - Fax:
Practice Address - Street 1:373 MARTIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-4108
Practice Address - Country:US
Practice Address - Phone:210-289-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2016-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60578253133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty