Provider Demographics
NPI:1912632266
Name:BALANCED NUTRITION NW LLC
Entity Type:Organization
Organization Name:BALANCED NUTRITION NW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PADRON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:971-419-8549
Mailing Address - Street 1:20369 HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-9012
Mailing Address - Country:US
Mailing Address - Phone:971-419-8549
Mailing Address - Fax:971-229-4024
Practice Address - Street 1:20369 HOMESTEAD DR
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-9012
Practice Address - Country:US
Practice Address - Phone:971-419-8549
Practice Address - Fax:971-229-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-20
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1972131001Medicaid