Healthcare Provider Details

I. General information

NPI: 1699254532
Provider Name (Legal Business Name): IKIGAI NUTRITION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2018
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 WILSHIRE BLVD STE 604
LOS ANGELES CA
90024-6325
US

IV. Provider business mailing address

10501 WILSHIRE BLVD UNIT 1703
LOS ANGELES CA
90024-6318
US

V. Phone/Fax

Practice location:
  • Phone: 323-628-3158
  • Fax:
Mailing address:
  • Phone: 323-628-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number86108369
License Number StateCA

VIII. Authorized Official

Name: ANGIE WU
Title or Position: CEO
Credential: MS, RDN
Phone: 323-628-3158