Provider Demographics
NPI:1265989776
Name:EAT LIVE NUTRITION, PLLC
Entity type:Organization
Organization Name:EAT LIVE NUTRITION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CDN
Authorized Official - Phone:585-703-2739
Mailing Address - Street 1:198 OEHMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1608
Mailing Address - Country:US
Mailing Address - Phone:585-703-2739
Mailing Address - Fax:
Practice Address - Street 1:1026 UNION RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3445
Practice Address - Country:US
Practice Address - Phone:716-217-1004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007596-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1811252604OtherNPI
NYJ400201451OtherMEDICARE