Healthcare Provider Details

I. General information

NPI: 1831969047
Provider Name (Legal Business Name): DIANNA REILLY NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 3RD ST APT 104
SANTA MONICA CA
90403-2544
US

IV. Provider business mailing address

924 3RD ST. 104
SANTA MONICA CA
90403
US

V. Phone/Fax

Practice location:
  • Phone: 424-501-5265
  • Fax: 424-442-1557
Mailing address:
  • Phone: 424-501-5265
  • Fax: 424-442-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANNA MARINO REILLY
Title or Position: REGISTERED DIETITIAN
Credential: RD
Phone: 424-501-5265