Provider Demographics
NPI:1902009475
Name:LIFE STYLES NUTRITION SERVICES
Entity Type:Organization
Organization Name:LIFE STYLES NUTRITION SERVICES
Other - Org Name:NUTRITION TO GO
Other - Org Type:Other Name
Authorized Official - Title/Position:INDEPENDENT CONTRACTOR & PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:616-929-4026
Mailing Address - Street 1:1550 GIDDINGS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-2223
Mailing Address - Country:US
Mailing Address - Phone:616-929-4026
Mailing Address - Fax:
Practice Address - Street 1:1550 GIDDINGS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507
Practice Address - Country:US
Practice Address - Phone:616-560-5696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI723477133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty