Healthcare Provider Details

I. General information

NPI: 1720684228
Provider Name (Legal Business Name): BEACHSIDE NUTRITION CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 01/22/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 2ND ST APT 330
HERMOSA BEACH CA
90254-4610
US

IV. Provider business mailing address

29 ETHELWOOD CT
OLNEY MD
20832-2900
US

V. Phone/Fax

Practice location:
  • Phone: 301-996-2927
  • Fax:
Mailing address:
  • Phone: 301-996-2927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BROOKE AMELIA MADER
Title or Position: NUTRITIONIST
Credential: MS, CNS, LDN
Phone: 301-996-2927