Healthcare Provider Details

I. General information

NPI: 1790312411
Provider Name (Legal Business Name): RACER'S EDGE NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 S ELM ST
DENVER CO
80222-7352
US

IV. Provider business mailing address

3075 S ELM ST
DENVER CO
80222-7352
US

V. Phone/Fax

Practice location:
  • Phone: 516-317-9216
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: NICOLE RUBENSTEIN
Title or Position: REGISTERED DIETITIAN
Credential: MS, RD, CSSD, CDE
Phone: 516-317-9216