Provider Demographics
NPI:1942075221
Name:NUTRIBLE FOUNDATION INC.
Entity Type:Organization
Organization Name:NUTRIBLE FOUNDATION INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KWAMANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:JD, MHA, BSN
Authorized Official - Phone:708-502-2828
Mailing Address - Street 1:7400 CENTER AVE APT 333
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-9176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:989 S ALICE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7864
Practice Address - Country:US
Practice Address - Phone:562-516-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty