Provider Demographics
NPI:1952080848
Name:IMAGINABLE NUTRITION LLC
Entity Type:Organization
Organization Name:IMAGINABLE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:DRU
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:304-389-3336
Mailing Address - Street 1:15 WARREN PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3613
Mailing Address - Country:US
Mailing Address - Phone:304-389-3336
Mailing Address - Fax:
Practice Address - Street 1:15 WARREN PL
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3613
Practice Address - Country:US
Practice Address - Phone:304-389-3336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty