Provider Demographics
NPI:1366922734
Name:CHERRY CITY NUTRITION
Entity type:Organization
Organization Name:CHERRY CITY NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:971-273-8668
Mailing Address - Street 1:5113 CHERRY HOLLOW LN S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9634
Mailing Address - Country:US
Mailing Address - Phone:971-273-8668
Mailing Address - Fax:
Practice Address - Street 1:780 COMMERCIAL ST SE STE 305
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3455
Practice Address - Country:US
Practice Address - Phone:971-273-8668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10144657133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
962738OtherCOMMISSION ON DIETETIC REGISTRATION
ORLD-D-10144657OtherSTATE OF OREGON