Provider Demographics
NPI:1639632912
Name:LIFELONG NUTRITION AND FITNESS INC
Entity Type:Organization
Organization Name:LIFELONG NUTRITION AND FITNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUDAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-743-4078
Mailing Address - Street 1:816 N O ST SPC 88
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-8085
Mailing Address - Country:US
Mailing Address - Phone:805-743-4078
Mailing Address - Fax:
Practice Address - Street 1:1010 N H ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-3305
Practice Address - Country:US
Practice Address - Phone:805-743-4078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty