Healthcare Provider Details

I. General information

NPI: 1346935665
Provider Name (Legal Business Name): BIONUTRAX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 9TH ST APT A
SANTA MONICA CA
90404-4577
US

IV. Provider business mailing address

1806 9TH ST APT A
SANTA MONICA CA
90404-4577
US

V. Phone/Fax

Practice location:
  • Phone: 323-481-1787
  • Fax:
Mailing address:
  • Phone: 323-481-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: DR. AIKATERINI KATHY XYDIS
Title or Position: OWNER, DOCTOR OF CLINICAL NUTRITION
Credential: DCN, CNS, LDN
Phone: 323-481-1787