Provider Demographics
NPI:1265741748
Name:NUTRITION CORE, LLC
Entity type:Organization
Organization Name:NUTRITION CORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:BROOK
Authorized Official - Last Name:BUNNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSHA, RD/LD
Authorized Official - Phone:918-557-0022
Mailing Address - Street 1:15336 E 470 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-5372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 N HIGHWAY 66
Practice Address - Street 2:SUITE B
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2460
Practice Address - Country:US
Practice Address - Phone:918-557-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1312133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1285716803OtherNPI
OK200049320BMedicaid