Provider Demographics
NPI:1932761418
Name:MAVERICK NUTRITION LLC
Entity Type:Organization
Organization Name:MAVERICK NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SARVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-821-0863
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-0357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:919 7TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4104
Practice Address - Country:US
Practice Address - Phone:740-370-9416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty