Provider Demographics
NPI:1013529411
Name:RENEGADE NUTRITION LLC
Entity Type:Organization
Organization Name:RENEGADE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:408-460-7319
Mailing Address - Street 1:33947 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-3431
Mailing Address - Country:US
Mailing Address - Phone:408-460-7319
Mailing Address - Fax:
Practice Address - Street 1:33947 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-3431
Practice Address - Country:US
Practice Address - Phone:408-460-7319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1205303260Medicaid