Provider Demographics
NPI:1063102556
Name:LIFESTYLES IN NUTRITION
Entity type:Organization
Organization Name:LIFESTYLES IN NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DIETITIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:425-633-2022
Mailing Address - Street 1:16550 NE 79TH ST APT 121
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-2474
Mailing Address - Country:US
Mailing Address - Phone:425-633-2022
Mailing Address - Fax:888-538-8128
Practice Address - Street 1:10900 NE 4TH ST STE 2300
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5882
Practice Address - Country:US
Practice Address - Phone:425-633-2022
Practice Address - Fax:888-538-8128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty