Provider Demographics
NPI:1427559988
Name:NOURISH TO REVIVE, LLC
Entity type:Organization
Organization Name:NOURISH TO REVIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ HEALTHCARE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MFN, RDN, CLT
Authorized Official - Phone:419-567-2554
Mailing Address - Street 1:439 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-4205
Mailing Address - Country:US
Mailing Address - Phone:416-567-2554
Mailing Address - Fax:
Practice Address - Street 1:439 4TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-4205
Practice Address - Country:US
Practice Address - Phone:419-567-2554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD7029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty