Provider Demographics
NPI:1740605088
Name:TAILORED NUTRITION LLC
Entity Type:Organization
Organization Name:TAILORED NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:FLETCHER
Authorized Official - Last Name:BOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RD,LD,CSO
Authorized Official - Phone:307-752-8213
Mailing Address - Street 1:37 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4221
Mailing Address - Country:US
Mailing Address - Phone:307-752-8213
Mailing Address - Fax:307-675-1866
Practice Address - Street 1:37 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4221
Practice Address - Country:US
Practice Address - Phone:307-752-8213
Practice Address - Fax:307-675-1866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-24
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY81261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW26005Medicare PIN