Healthcare Provider Details

I. General information

NPI: 1730436064
Provider Name (Legal Business Name): PEACE OF NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 WALDO ST SUITE 205
ST AUGUSTINE FL
32084-2718
US

IV. Provider business mailing address

301 ELEUTHERA CT
ST AUGUSTINE FL
32095-9617
US

V. Phone/Fax

Practice location:
  • Phone: 904-377-6190
  • Fax: 904-808-4702
Mailing address:
  • Phone: 904-377-6190
  • Fax: 904-808-4702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberND 5445
License Number StateFL

VIII. Authorized Official

Name: AMANDA PERRIN
Title or Position: OWNER/LEAD DIETITIAN
Credential: RD, LD/N
Phone: 904-377-6190