Healthcare Provider Details

I. General information

NPI: 1992446181
Provider Name (Legal Business Name): GOGLIA NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 28TH ST STE 133
SANTA MONICA CA
90405-6204
US

IV. Provider business mailing address

1220 ROSECRANS ST # 297
SAN DIEGO CA
92106-2674
US

V. Phone/Fax

Practice location:
  • Phone: 619-220-9009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JOHN LEVAN
Title or Position: CPO
Credential:
Phone: 919-449-4857