Healthcare Provider Details

I. General information

NPI: 1841697208
Provider Name (Legal Business Name): NICHOLE URBAN R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS NICHOLE BALANDRAN

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 11/12/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3782 W MARTIN LUTHER KING JR BLVD
LOS ANGELES CA
90008-1703
US

IV. Provider business mailing address

12135 MITCHELL AVE APT 103
LOS ANGELES CA
90066-4538
US

V. Phone/Fax

Practice location:
  • Phone: 323-421-2710
  • Fax:
Mailing address:
  • Phone: 760-218-4489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number1081293
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1081293
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: