Provider Demographics
NPI:1497378723
Name:NUTRITION 4 BODY AND MIND LLC
Entity Type:Organization
Organization Name:NUTRITION 4 BODY AND MIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAPHNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALIZAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-812-8380
Mailing Address - Street 1:10040 BAYSTONE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-8690
Mailing Address - Country:US
Mailing Address - Phone:702-812-8380
Mailing Address - Fax:
Practice Address - Street 1:6671 S. LAS VEGAS BLVD.
Practice Address - Street 2:BLDG. D, SUITE 210
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3273
Practice Address - Country:US
Practice Address - Phone:702-812-8380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty