Provider Demographics
NPI:1053980763
Name:NOURISHED ONE
Entity type:Organization
Organization Name:NOURISHED ONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:CNS
Authorized Official - Phone:817-542-6323
Mailing Address - Street 1:6161 NW 2ND AVE APT 214
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-3047
Mailing Address - Country:US
Mailing Address - Phone:817-542-6323
Mailing Address - Fax:
Practice Address - Street 1:6161 NW 2ND AVE APT 214
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-3047
Practice Address - Country:US
Practice Address - Phone:817-542-6323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty