Provider Demographics
NPI:1497344998
Name:SHAPE YOUR GRAPE
Entity Type:Organization
Organization Name:SHAPE YOUR GRAPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:818-658-1130
Mailing Address - Street 1:350 N GLENDALE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-3323
Mailing Address - Country:US
Mailing Address - Phone:818-658-1130
Mailing Address - Fax:
Practice Address - Street 1:728 CORDOVA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-2114
Practice Address - Country:US
Practice Address - Phone:818-472-6616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty