Healthcare Provider Details

I. General information

NPI: 1790258465
Provider Name (Legal Business Name): BGB NUTRITION INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2019
Last Update Date: 01/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6940 E LYRA DR
SCOTTSDALE AZ
85257-3369
US

IV. Provider business mailing address

PO BOX 1360
SCOTTSDALE AZ
85252-1360
US

V. Phone/Fax

Practice location:
  • Phone: 832-724-6266
  • Fax:
Mailing address:
  • Phone: 832-724-6266
  • 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. BRIANA GILBREATH BUTLER
Title or Position: OWNER
Credential:
Phone: 832-724-6266