Provider Demographics
NPI:1629582796
Name:BASIC BALANCE NUTRITION, INC.
Entity Type:Organization
Organization Name:BASIC BALANCE NUTRITION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BONIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD
Authorized Official - Phone:936-337-2981
Mailing Address - Street 1:1217 AVENUE M STE 113
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-4650
Mailing Address - Country:US
Mailing Address - Phone:936-337-2981
Mailing Address - Fax:936-755-5115
Practice Address - Street 1:1217 AVENUE M STE 113
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340
Practice Address - Country:US
Practice Address - Phone:936-337-2981
Practice Address - Fax:936-755-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-27
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84230133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty