Provider Demographics
NPI:1154006542
Name:NUTRITION UPGRADE LLC
Entity type:Organization
Organization Name:NUTRITION UPGRADE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:208-699-0605
Mailing Address - Street 1:PO BOX 1513
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:924 N 17TH ST
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5551
Practice Address - Country:US
Practice Address - Phone:208-699-0605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty