Provider Demographics
NPI:1104400183
Name:YOUR DIETITIAN FOR LIFE LLC
Entity Type:Organization
Organization Name:YOUR DIETITIAN FOR LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARA
Authorized Official - Middle Name:
Authorized Official - Last Name:AXELROD
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:954-850-2926
Mailing Address - Street 1:15901 SURREY CIR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33331-2571
Mailing Address - Country:US
Mailing Address - Phone:954-850-2926
Mailing Address - Fax:
Practice Address - Street 1:15901 SURREY CIR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33331-2571
Practice Address - Country:US
Practice Address - Phone:954-850-2926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty