Provider Demographics
NPI:1760016737
Name:STILL I THRIVE FUNCTIONAL NUTRITION LLC
Entity Type:Organization
Organization Name:STILL I THRIVE FUNCTIONAL NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORAL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:781-589-4127
Mailing Address - Street 1:10866 WASHINGTON BLVD # 175
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3713 KELTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-7119
Practice Address - Country:US
Practice Address - Phone:781-589-4127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-27
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1447896444OtherNPI