Provider Demographics
NPI:1689919326
Name:WHOLE IMPACT NUTRITION, LLC
Entity Type:Organization
Organization Name:WHOLE IMPACT NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER & ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTINE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:910-409-3996
Mailing Address - Street 1:4205 RIVER BIRCH LOOP
Mailing Address - Street 2:APT 3A
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-8048
Mailing Address - Country:US
Mailing Address - Phone:910-409-3996
Mailing Address - Fax:
Practice Address - Street 1:4205 RIVER BIRCH LOOP
Practice Address - Street 2:APT 3A
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-8048
Practice Address - Country:US
Practice Address - Phone:910-409-3996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003743133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty