Provider Demographics
NPI:1821698739
Name:HEIDARI, HOOMAN (MBA, MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:HOOMAN
Middle Name:
Last Name:HEIDARI
Suffix:
Gender:M
Credentials:MBA, MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 PINE LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-1517
Mailing Address - Country:US
Mailing Address - Phone:310-430-9790
Mailing Address - Fax:
Practice Address - Street 1:7305 N MILITARY TRL
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-7417
Practice Address - Country:US
Practice Address - Phone:561-422-8262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10108133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered