Provider Demographics
NPI:1477330603
Name:VITAL NUTRITION DIETITIAN
Entity Type:Organization
Organization Name:VITAL NUTRITION DIETITIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BREEDON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:734-755-4975
Mailing Address - Street 1:4083 SW 49TH TER
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-9684
Mailing Address - Country:US
Mailing Address - Phone:734-755-4975
Mailing Address - Fax:352-352-9390
Practice Address - Street 1:4083 SW 49TH TER
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-9684
Practice Address - Country:US
Practice Address - Phone:734-755-4975
Practice Address - Fax:352-352-9390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty