Provider Demographics
NPI:1942817580
Name:NOURISHED LIVING LLC
Entity Type:Organization
Organization Name:NOURISHED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATUS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:313-288-2680
Mailing Address - Street 1:676 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1278
Mailing Address - Country:US
Mailing Address - Phone:313-288-2680
Mailing Address - Fax:
Practice Address - Street 1:22811 GREATER MACK AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2054
Practice Address - Country:US
Practice Address - Phone:248-288-2680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty