Healthcare Provider Details

I. General information

NPI: 1548176456
Provider Name (Legal Business Name): SURGICALRX NUTRITION THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 N 22ND ST # 7301
PHOENIX AZ
85016-4639
US

IV. Provider business mailing address

1311 VINE ST
CINCINNATI OH
45202-7118
US

V. Phone/Fax

Practice location:
  • Phone: 602-429-9127
  • Fax:
Mailing address:
  • Phone: 602-429-9127
  • 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: DYLAN BOURELLE
Title or Position: OPERATOR
Credential:
Phone: 602-429-9127