Provider Demographics
NPI:1013522481
Name:HUMLIE MEDICAL NUTRITION CARE LLC
Entity Type:Organization
Organization Name:HUMLIE MEDICAL NUTRITION CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:ANASTASIA
Authorized Official - Last Name:HUMLIE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:503-883-1724
Mailing Address - Street 1:109 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-4603
Mailing Address - Country:US
Mailing Address - Phone:503-883-1724
Mailing Address - Fax:855-966-4121
Practice Address - Street 1:109 W 8TH ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-4603
Practice Address - Country:US
Practice Address - Phone:503-883-1724
Practice Address - Fax:855-966-4121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-12
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10209651OtherLICENSE NUMBER