Provider Demographics
NPI:1922768993
Name:NUTRITION FOR PERFORMANCE
Entity Type:Organization
Organization Name:NUTRITION FOR PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:360-441-0349
Mailing Address - Street 1:56 PRINCE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02113-1826
Mailing Address - Country:US
Mailing Address - Phone:360-441-0349
Mailing Address - Fax:
Practice Address - Street 1:31 SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-4101
Practice Address - Country:US
Practice Address - Phone:360-441-0349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1083220586Medicaid