Provider Demographics
NPI:1073167409
Name:LIFESTYLE NUTRITION & DIETETICS
Entity Type:Organization
Organization Name:LIFESTYLE NUTRITION & DIETETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RD
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-830-2551
Mailing Address - Street 1:9100 SEAVEY LN
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-8898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:970 RESERVE DR STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-1377
Practice Address - Country:US
Practice Address - Phone:530-830-2551
Practice Address - Fax:916-970-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty