Healthcare Provider Details

I. General information

NPI: 1255084810
Provider Name (Legal Business Name): DD HIZZLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 PALATINE APT 451
IRVINE CA
92612-7627
US

IV. Provider business mailing address

25 PALATINE APT 451
IRVINE CA
92612-7627
US

V. Phone/Fax

Practice location:
  • Phone: 310-993-1197
  • Fax:
Mailing address:
  • Phone: 310-993-1197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: DOROTHY DAWN MALSACK
Title or Position: CEO
Credential: RDN
Phone: 949-371-6947