MEDICARE: REILLY BEATTY SPORTS NUTRITION 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	133VN1501X	Sports Dietetics Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1598624397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REILLY BEATTY SPORTS NUTRITION LLC

Provider Business Mailing Address
First Line	:	728 SURREY PATH TRL
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-5035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	728 SURREY PATH TRL
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27104-5035
Country	:	US
Telephone Number	:	424-346-3037
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	REILLY BEATTY
Credential	:	RD, MS, CSSD
Telephone Number	:	424-346-3037

Provider Enumeration Date	:	01/17/2026
Last Update Date	:	01/17/2026

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