Healthcare Provider Details

I. General information

NPI: 1285598102
Provider Name (Legal Business Name): PUREVITAL NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10752 DEERWOOD PARK BLVD STE 100
JACKSONVILLE FL
32256-4846
US

IV. Provider business mailing address

5274 LEGACY PINES WAY
JACKSONVILLE FL
32224-4410
US

V. Phone/Fax

Practice location:
  • Phone: 904-763-9722
  • Fax: 904-833-3377
Mailing address:
  • Phone: 904-763-9722
  • Fax: 904-833-3377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MERCEDES WAUGAMAN
Title or Position: OWNER
Credential:
Phone: 904-763-9722