Provider Demographics
NPI:1225861040
Name:MIDWEST PERFORMANCE NUTRITION LLC
Entity type:Organization
Organization Name:MIDWEST PERFORMANCE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ABIGAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:OLCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-397-6406
Mailing Address - Street 1:8060 LEXINGTON PL APT 10
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-2511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8060 LEXINGTON PL APT 10
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2511
Practice Address - Country:US
Practice Address - Phone:309-397-6406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports DieteticsGroup - Single Specialty