Provider Demographics
NPI:1659157642
Name:TYPE 2 THRIVING
Entity Type:Organization
Organization Name:TYPE 2 THRIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOU
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDCES, ACE-CPT
Authorized Official - Phone:562-276-8057
Mailing Address - Street 1:17901 PIONEER BLVD STE L113
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90701-3952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1716 E 53RD ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6214
Practice Address - Country:US
Practice Address - Phone:562-276-8057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-05
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty