Provider Demographics
NPI:1669129557
Name:MAKE LIFE PEACHY
Entity type:Organization
Organization Name:MAKE LIFE PEACHY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:713-416-8829
Mailing Address - Street 1:22426 CARRIAGE BUSH
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-4416
Mailing Address - Country:US
Mailing Address - Phone:713-416-8829
Mailing Address - Fax:
Practice Address - Street 1:22426 CARRIAGE BUSH
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78261-4416
Practice Address - Country:US
Practice Address - Phone:713-416-8829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty