Healthcare Provider Details

I. General information

NPI: 1053222109
Provider Name (Legal Business Name): LIGHTHOUSE NUTRITION AND DIETETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3689 MOULTRIE AVE
SAN DIEGO CA
92117-5619
US

IV. Provider business mailing address

3689 MOULTRIE AVE
SAN DIEGO CA
92117-5619
US

V. Phone/Fax

Practice location:
  • Phone: 619-416-1771
  • Fax:
Mailing address:
  • Phone: 619-416-1771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: EDUARDO MIGUEL MENDEZ
Title or Position: REGISTERED DIETITIAN
Credential: RD, MPH
Phone: 619-416-1771