Healthcare Provider Details

I. General information

NPI: 1023881794
Provider Name (Legal Business Name): NUTRI-MED RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 LA TUNA CT
CAMARILLO CA
93012-4035
US

IV. Provider business mailing address

4605 LA TUNA CT
CAMARILLO CA
93012-4035
US

V. Phone/Fax

Practice location:
  • Phone: 805-312-5796
  • Fax: 805-764-8601
Mailing address:
  • Phone: 805-312-5796
  • Fax: 805-764-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DESTINY WARREN
Title or Position: CEO
Credential: RDN
Phone: 805-312-5796