Provider Demographics
NPI:1780851790
Name:CUSTOM FIT NUTRITION, LLC
Entity type:Organization
Organization Name:CUSTOM FIT NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SUPPLEE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CD
Authorized Official - Phone:206-295-6810
Mailing Address - Street 1:21230 SE 270TH ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-3142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21230 SE 270TH ST
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-3142
Practice Address - Country:US
Practice Address - Phone:206-295-6810
Practice Address - Fax:877-532-1805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00002000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty