Provider Demographics
NPI:1023610615
Name:INNOVATIVE NUTRITION LLC
Entity type:Organization
Organization Name:INNOVATIVE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GACEK
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD
Authorized Official - Phone:205-305-2840
Mailing Address - Street 1:2889 SOLLIE RD APT 303
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-5535
Mailing Address - Country:US
Mailing Address - Phone:205-305-2840
Mailing Address - Fax:
Practice Address - Street 1:100 MEMORIAL HOSPITAL DR STE 3C
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1185
Practice Address - Country:US
Practice Address - Phone:251-272-9654
Practice Address - Fax:251-243-4942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty