Provider Demographics
NPI:1336618636
Name:INNOVATIVE NUTRITION GROUP
Entity type:Organization
Organization Name:INNOVATIVE NUTRITION GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSO
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:602-430-8405
Mailing Address - Street 1:6501 E GREENWAY PKWY STE 103-195
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-2025
Mailing Address - Country:US
Mailing Address - Phone:602-430-8405
Mailing Address - Fax:
Practice Address - Street 1:5350 E MARILYN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-2346
Practice Address - Country:US
Practice Address - Phone:602-430-8405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center