Healthcare Provider Details

I. General information

NPI: 1811570401
Provider Name (Legal Business Name): PURE NUTRITION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 POLARIS DR
TUSTIN CA
92782-1720
US

IV. Provider business mailing address

830 POLARIS DR
TUSTIN CA
92782-1720
US

V. Phone/Fax

Practice location:
  • Phone: 949-870-7506
  • Fax:
Mailing address:
  • Phone: 949-870-7506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: EILEEN HSIUNG
Title or Position: PRESIDENT
Credential: RDN
Phone: 949-870-7506