MEDICARE: PERSONALIZED NUTRITION COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1093305625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERSONALIZED NUTRITION COUNSELING LLC

Provider Business Mailing Address
First Line	:	1 VACAVILLE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92602-0915
Country	:	US
Telephone Number	:	949-689-5039
Fax Number	:

Provider Business Practice Location Address
First Line	:	12240 VENICE BLVD STE 30
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-3891
Country	:	US
Telephone Number	:	949-689-5039
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SARA KASHLAN
Credential	:	RD
Telephone Number	:	949-689-5039

Provider Enumeration Date	:	01/18/2021
Last Update Date	:	01/18/2021

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