Healthcare Provider Details

I. General information

NPI: 1316834708
Provider Name (Legal Business Name): NUTRILACT CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 SW 41 STREET, UNIT 216
HOLLYWOOD FL
33023-6988
US

IV. Provider business mailing address

PO BOX 19187
PLANTATION FL
33318-0187
US

V. Phone/Fax

Practice location:
  • Phone: 954-513-7159
  • 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 Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name: GEROMINA RAPHAEL
Title or Position: OWNER, REGISTERED DIETITIAN
Credential: RD
Phone: 954-513-7159