Healthcare Provider Details

I. General information

NPI: 1316724321
Provider Name (Legal Business Name): NUTRIBALANCE DIETETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31976 LAZY GLEN LN
TRABUCO CANYON CA
92679-3217
US

IV. Provider business mailing address

31976 LAZY GLEN LN
TRABUCO CANYON CA
92679-3217
US

V. Phone/Fax

Practice location:
  • Phone: 949-636-4907
  • Fax:
Mailing address:
  • Phone: 949-636-4907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: THERESA HELMUTH
Title or Position: REGISTERED DIETITIAN
Credential: RDN, CSR
Phone: 949-636-4907