Healthcare Provider Details

I. General information

NPI: 1124790811
Provider Name (Legal Business Name): HAIKU NUTRITIONAL EMPOWERMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15212 N 2ND ST
PHOENIX AZ
85022-3610
US

IV. Provider business mailing address

15212 N 2ND ST
PHOENIX AZ
85022-3610
US

V. Phone/Fax

Practice location:
  • Phone: 602-935-8791
  • Fax:
Mailing address:
  • Phone: 602-935-8791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLY RENEE ROBERS
Title or Position: CEO
Credential: RDN, CDCES
Phone: 602-935-8791