Provider Demographics
NPI:1184329088
Name:FULLY FUNCTIONAL NUTRITION LLC
Entity type:Organization
Organization Name:FULLY FUNCTIONAL NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD
Authorized Official - Phone:732-710-7915
Mailing Address - Street 1:1419 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6459
Mailing Address - Country:US
Mailing Address - Phone:732-710-7915
Mailing Address - Fax:
Practice Address - Street 1:1419 E 9TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-6459
Practice Address - Country:US
Practice Address - Phone:732-710-7915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty