Provider Demographics
NPI:1457928467
Name:OPEN CONCEPT NUTRITION LLC
Entity Type:Organization
Organization Name:OPEN CONCEPT NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:NELLESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:715-308-3895
Mailing Address - Street 1:W2713 730TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54767-8512
Mailing Address - Country:US
Mailing Address - Phone:715-308-3895
Mailing Address - Fax:
Practice Address - Street 1:W2713 730TH AVE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:WI
Practice Address - Zip Code:54767-8512
Practice Address - Country:US
Practice Address - Phone:715-308-3895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861904534OtherNPI