Provider Demographics
NPI:1790287563
Name:IDAHO NUTRITION AND WELLNESS CLINIC
Entity Type:Organization
Organization Name:IDAHO NUTRITION AND WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, REGISTERED DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERNIER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD, LMT
Authorized Official - Phone:208-789-9664
Mailing Address - Street 1:894 E BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5122
Mailing Address - Country:US
Mailing Address - Phone:208-813-6015
Mailing Address - Fax:
Practice Address - Street 1:894 E BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5122
Practice Address - Country:US
Practice Address - Phone:208-789-9664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID011885Medicaid