Provider Demographics
NPI:1003210543
Name:FOREVER NUTRITION LLC
Entity type:Organization
Organization Name:FOREVER NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:RD LD CDE
Authorized Official - Phone:314-805-2997
Mailing Address - Street 1:2639 GLOBE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-4473
Mailing Address - Country:US
Mailing Address - Phone:314-805-2997
Mailing Address - Fax:
Practice Address - Street 1:10000 N CENTRAL EXPY
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4177
Practice Address - Country:US
Practice Address - Phone:314-805-2997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83424133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
142130002Medicare PIN