Healthcare Provider Details

I. General information

NPI: 1033629175
Provider Name (Legal Business Name): 360 NUTRITION CONSULTING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MOBIL AVE STE D9
CAMARILLO CA
93010-6376
US

IV. Provider business mailing address

400 MOBIL AVE STE D9
CAMARILLO CA
93010-6376
US

V. Phone/Fax

Practice location:
  • Phone: 805-738-5700
  • Fax:
Mailing address:
  • Phone: 805-738-5700
  • Fax: 805-738-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KELSEA JOHANNA PALACE
Title or Position: OWNER
Credential: RDN
Phone: 805-444-5919