Provider Demographics
NPI:1689181976
Name:KC NUTRITION, LLC
Entity Type:Organization
Organization Name:KC NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:COUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, LD
Authorized Official - Phone:541-279-3696
Mailing Address - Street 1:PO BOX 6232
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1693 SW CHANDLER AVE STE 140
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3230
Practice Address - Country:US
Practice Address - Phone:541-279-3696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01013025133N00000X
ORLD-D-10177506133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801333935OtherDEPARTMENT HEALTH AND HUMAN SERVICES