Provider Demographics
NPI:1659782167
Name:BROOKE DOUGLAS; NUTRITION AUTHORITY
Entity Type:Organization
Organization Name:BROOKE DOUGLAS; NUTRITION AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, CD
Authorized Official - Phone:253-227-8284
Mailing Address - Street 1:15308 136 AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374
Mailing Address - Country:US
Mailing Address - Phone:253-227-8284
Mailing Address - Fax:206-350-2612
Practice Address - Street 1:3806 9TH ST SW
Practice Address - Street 2:SUITE C
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373
Practice Address - Country:US
Practice Address - Phone:253-227-8284
Practice Address - Fax:206-350-2612
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKE DOUGLAS; NUTRITION AUTHORITY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
#706866133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty