Provider Demographics
NPI:1124477104
Name:BRIGHT SKY NUTRITION, LLC
Entity type:Organization
Organization Name:BRIGHT SKY NUTRITION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CDE
Authorized Official - Phone:417-343-8222
Mailing Address - Street 1:3243 W KATELLA CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-8713
Mailing Address - Country:US
Mailing Address - Phone:417-343-8222
Mailing Address - Fax:866-542-3416
Practice Address - Street 1:3543 S LONE PINE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4854
Practice Address - Country:US
Practice Address - Phone:417-343-8222
Practice Address - Fax:866-542-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004029834261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073807384Medicaid