Healthcare Provider Details

I. General information

NPI: 1306334578
Provider Name (Legal Business Name): SEASIDE NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 MOHEGAN RD
ST AUGUSTINE FL
32086-6023
US

IV. Provider business mailing address

PO BOX 1568
SAINT AUGUSTINE FL
32085-1568
US

V. Phone/Fax

Practice location:
  • Phone: 904-540-2503
  • Fax:
Mailing address:
  • Phone: 904-540-2503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND7315
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86032198
License Number StateFL

VIII. Authorized Official

Name: KERI BOMARITO
Title or Position: OWNER
Credential: RD, LD/N
Phone: 904-540-2503