Provider Demographics
NPI:1780269902
Name:DYNAMIC NUTRITION NW LLC
Entity type:Organization
Organization Name:DYNAMIC NUTRITION NW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVANGELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FACCHINE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CD
Authorized Official - Phone:732-986-2633
Mailing Address - Street 1:5811 187TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8620
Mailing Address - Country:US
Mailing Address - Phone:425-470-3458
Mailing Address - Fax:425-372-7941
Practice Address - Street 1:5811 187TH AVE SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8620
Practice Address - Country:US
Practice Address - Phone:425-470-3458
Practice Address - Fax:425-372-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1255995973OtherNPI