Provider Demographics
NPI:1821504093
Name:SHAPE UP NUTRITION LLC
Entity Type:Organization
Organization Name:SHAPE UP NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DEFURIA
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN
Authorized Official - Phone:908-285-8880
Mailing Address - Street 1:4300 S BEACH PKWY APT 3208
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-8181
Mailing Address - Country:US
Mailing Address - Phone:908-285-8880
Mailing Address - Fax:
Practice Address - Street 1:4300 S BEACH PKWY APT 3208
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-8181
Practice Address - Country:US
Practice Address - Phone:908-285-8880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-23
Last Update Date:2017-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7872133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty