Provider Demographics
NPI:1801224282
Name:WILDER NUTRITION SOLUTIONS LLC
Entity Type:Organization
Organization Name:WILDER NUTRITION SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DARBIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:813-748-9303
Mailing Address - Street 1:184 VALENCIA CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1298
Mailing Address - Country:US
Mailing Address - Phone:813-748-9303
Mailing Address - Fax:
Practice Address - Street 1:184 VALENCIA CIR
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1298
Practice Address - Country:US
Practice Address - Phone:813-748-9303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5225133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty