Healthcare Provider Details

I. General information

NPI: 1932653615
Provider Name (Legal Business Name): THE GUT RD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 SUNTREE BLVD STE 101
ROCKLEDGE FL
32955-5741
US

IV. Provider business mailing address

440 45TH AVE
VERO BEACH FL
32968-1866
US

V. Phone/Fax

Practice location:
  • Phone: 772-971-9006
  • Fax:
Mailing address:
  • Phone: 772-971-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 7447
License Number StateFL

VIII. Authorized Official

Name: CHRISTI N BUCK
Title or Position: OWNER
Credential: RDN, LD
Phone: 772-971-9006