Provider Demographics
NPI:1235769670
Name:MODERN NUTRITION NW LLC
Entity type:Organization
Organization Name:MODERN NUTRITION NW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:SUZZANNE
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:MS RDN LD
Authorized Official - Phone:503-313-6461
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-0493
Mailing Address - Country:US
Mailing Address - Phone:503-650-3801
Mailing Address - Fax:503-650-7002
Practice Address - Street 1:7003 SE YEARLING LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97267-1983
Practice Address - Country:US
Practice Address - Phone:503-650-3801
Practice Address - Fax:503-650-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service