Provider Demographics
NPI:1891017893
Name:LOVE NUTRITION 4 LIFE, INC
Entity Type:Organization
Organization Name:LOVE NUTRITION 4 LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:LUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD
Authorized Official - Phone:404-441-8853
Mailing Address - Street 1:P.O. BOX 961831
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-7205
Mailing Address - Country:US
Mailing Address - Phone:404-441-8853
Mailing Address - Fax:
Practice Address - Street 1:313 BROOKVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-7205
Practice Address - Country:US
Practice Address - Phone:404-441-8853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003459133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G706418Medicare PIN