Provider Demographics
NPI:1205016888
Name:YOUR DIETITIAN FOR DIABETES & WEIGHT CONTROL, LLC
Entity Type:Organization
Organization Name:YOUR DIETITIAN FOR DIABETES & WEIGHT CONTROL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:DIONE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDE
Authorized Official - Phone:702-525-7703
Mailing Address - Street 1:11641 REDWOOD MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-6283
Mailing Address - Country:US
Mailing Address - Phone:702-525-7703
Mailing Address - Fax:702-666-8555
Practice Address - Street 1:7656 W SAHARA AVE STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2773
Practice Address - Country:US
Practice Address - Phone:702-525-1105
Practice Address - Fax:702-666-8555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NV2000255-320251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health