Provider Demographics
NPI:1053883520
Name:GREAT BASIN NUTRITION LLC
Entity type:Organization
Organization Name:GREAT BASIN NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:775-720-3490
Mailing Address - Street 1:783 BASQUE WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-7981
Mailing Address - Country:US
Mailing Address - Phone:775-720-3490
Mailing Address - Fax:775-245-2867
Practice Address - Street 1:783 BASQUE WAY STE 103
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-7981
Practice Address - Country:US
Practice Address - Phone:775-720-3490
Practice Address - Fax:775-245-2867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty