Provider Demographics
NPI:1669410197
Name:ADVANCED NUTRITION THERAPY, LLC
Entity type:Organization
Organization Name:ADVANCED NUTRITION THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:310-367-8190
Mailing Address - Street 1:3834 VISTA AZUL
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4542
Mailing Address - Country:US
Mailing Address - Phone:310-367-8190
Mailing Address - Fax:949-492-9492
Practice Address - Street 1:3834 VISTA AZUL
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4542
Practice Address - Country:US
Practice Address - Phone:310-367-8190
Practice Address - Fax:949-492-9492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21023Medicare PIN