Provider Demographics
NPI:1255675468
Name:PRO LIFESTYLE NUTRITION
Entity Type:Organization
Organization Name:PRO LIFESTYLE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUDES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:215-264-2574
Mailing Address - Street 1:405 LODGES LN
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2506
Mailing Address - Country:US
Mailing Address - Phone:215-264-2574
Mailing Address - Fax:
Practice Address - Street 1:405 LODGES LN
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2506
Practice Address - Country:US
Practice Address - Phone:215-264-2574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-12
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004844133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1063779791OtherINDIVIDUAL NPI