Healthcare Provider Details

I. General information

NPI: 1649902347
Provider Name (Legal Business Name): JEREMIAH MICHAEL FARIAS RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 US 1 S # 1050
SAINT AUGUSTINE FL
32086-6076
US

IV. Provider business mailing address

2465 US 1 S # 1050
SAINT AUGUSTINE FL
32086-6076
US

V. Phone/Fax

Practice location:
  • Phone: 626-201-8945
  • Fax:
Mailing address:
  • Phone: 626-201-8945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: