Healthcare Provider Details

I. General information

NPI: 1750130894
Provider Name (Legal Business Name): LIFEFUL AGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6633 W VIA MONTOYA DR
GLENDALE AZ
85310-5714
US

IV. Provider business mailing address

6633 W VIA MONTOYA DR
GLENDALE AZ
85310-5714
US

V. Phone/Fax

Practice location:
  • Phone: 480-813-9989
  • Fax:
Mailing address:
  • Phone: 480-813-9989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: BETTY HARBOLIC
Title or Position: FOUNDER
Credential: MS, RDN, BCC
Phone: 480-813-9989