Healthcare Provider Details

I. General information

NPI: 1619219631
Provider Name (Legal Business Name): EASTSIDE NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N WILMOT RD SUITE 340
TUCSON AZ
85711-2631
US

IV. Provider business mailing address

333 N WILMOT RD SUITE 340
TUCSON AZ
85711-2631
US

V. Phone/Fax

Practice location:
  • Phone: 520-618-5383
  • Fax: 520-918-3031
Mailing address:
  • Phone: 520-618-5383
  • Fax: 520-918-3031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: MRS. STEPHANIE NELSON JONES
Title or Position: OWNER/REGISTERRED DIETITIAN
Credential: MS,RD,CSSD
Phone: 520-618-5383