Provider Demographics
NPI:1669898193
Name:LIFESTYLE MEDICINE INSTITUTE
Entity type:Organization
Organization Name:LIFESTYLE MEDICINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DEVELOPMENT SUPPORT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAULIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:909-283-6005
Mailing Address - Street 1:25805 BARTON RD
Mailing Address - Street 2:BLDG. A, UNIT 106
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3814
Mailing Address - Country:US
Mailing Address - Phone:909-796-7676
Mailing Address - Fax:909-586-9342
Practice Address - Street 1:25805 BARTON RD
Practice Address - Street 2:BLDG. A, UNIT 106
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3814
Practice Address - Country:US
Practice Address - Phone:909-796-7676
Practice Address - Fax:909-586-9342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01107466133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty