Provider Demographics
NPI:1053179721
Name:MADDOX NUTRITION LLC
Entity type:Organization
Organization Name:MADDOX NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:LIESEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:719-445-9573
Mailing Address - Street 1:1942 BROADWAY STE 314C
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5233
Mailing Address - Country:US
Mailing Address - Phone:719-445-9573
Mailing Address - Fax:
Practice Address - Street 1:1942 BROADWAY STE 314C
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5233
Practice Address - Country:US
Practice Address - Phone:719-445-9573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty