Provider Demographics
NPI:1790512028
Name:AUTHENTIC HEALTH NUTRITION LLC
Entity type:Organization
Organization Name:AUTHENTIC HEALTH NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BUSINESS
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:217-552-2851
Mailing Address - Street 1:1506 BLUEGRASS LN
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1506 BLUEGRASS LN
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-2075
Practice Address - Country:US
Practice Address - Phone:217-552-2851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty