Provider Demographics
NPI:1477333599
Name:FOUR PILLARS NUTRITION AND WELLNESS, LLC
Entity type:Organization
Organization Name:FOUR PILLARS NUTRITION AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:POULSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:208-649-4171
Mailing Address - Street 1:147 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3425
Mailing Address - Country:US
Mailing Address - Phone:208-424-0179
Mailing Address - Fax:208-646-4394
Practice Address - Street 1:147 STANFORD AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3425
Practice Address - Country:US
Practice Address - Phone:208-649-4171
Practice Address - Fax:208-646-4394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty