Provider Demographics
NPI:1578927299
Name:WELL BALANCED NUTRITION, LLC
Entity Type:Organization
Organization Name:WELL BALANCED NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAYHURST
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN
Authorized Official - Phone:919-491-2004
Mailing Address - Street 1:2544 BURTON RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-3809
Mailing Address - Country:US
Mailing Address - Phone:919-491-2004
Mailing Address - Fax:
Practice Address - Street 1:2544 BURTON RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-3809
Practice Address - Country:US
Practice Address - Phone:919-491-2004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003447133N00000X, 133V00000X
NCL003670133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19DNY0OtherBLUE CROSS BLUE SHIELD