Healthcare Provider Details

I. General information

NPI: 1043015449
Provider Name (Legal Business Name): KJ NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14629 W OBERLIN WAY
SURPRISE AZ
85387-6747
US

IV. Provider business mailing address

14629 W OBERLIN WAY
SURPRISE AZ
85387-6747
US

V. Phone/Fax

Practice location:
  • Phone: 719-290-0002
  • Fax:
Mailing address:
  • Phone: 719-290-0002
  • 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: KELLI JO GROVER
Title or Position: OWNER/DIETITIAN
Credential: MDA, RDN
Phone: 719-290-0002