Provider Demographics
NPI:1376865360
Name:EAT WELL LIVE WELL INC
Entity Type:Organization
Organization Name:EAT WELL LIVE WELL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIRIJA
Authorized Official - Middle Name:S
Authorized Official - Last Name:AYYALA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CDN
Authorized Official - Phone:631-689-6528
Mailing Address - Street 1:22 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1019
Mailing Address - Country:US
Mailing Address - Phone:631-689-6528
Mailing Address - Fax:631-689-3074
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3159
Practice Address - Country:US
Practice Address - Phone:631-689-6528
Practice Address - Fax:631-689-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000673133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty