Provider Demographics
NPI:1679874184
Name:NOURISH YOUR BODY, LLC
Entity Type:Organization
Organization Name:NOURISH YOUR BODY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:CHASSEN
Authorized Official - Last Name:SOPOV
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:973-200-0896
Mailing Address - Street 1:71 BERGEN DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-1341
Mailing Address - Country:US
Mailing Address - Phone:973-200-0896
Mailing Address - Fax:844-436-5129
Practice Address - Street 1:1376 POMPTON AVE
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1011
Practice Address - Country:US
Practice Address - Phone:973-200-0896
Practice Address - Fax:844-436-5129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ933904133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ524390Medicare PIN