Provider Demographics
NPI:1588077226
Name:LORI S. BRIZEE PEDIATRIC NUTRITION CONSULTATION LLC
Entity type:Organization
Organization Name:LORI S. BRIZEE PEDIATRIC NUTRITION CONSULTATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN, OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRIZEE
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:541-306-6801
Mailing Address - Street 1:61456 ELDER RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1193
Mailing Address - Country:US
Mailing Address - Phone:541-788-2625
Mailing Address - Fax:541-312-4670
Practice Address - Street 1:516 SW 13TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3206
Practice Address - Country:US
Practice Address - Phone:541-306-6801
Practice Address - Fax:541-312-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD000706133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028359Medicaid
OR028359Medicaid