Healthcare Provider Details

I. General information

NPI: 1093487530
Provider Name (Legal Business Name): NUTRIPHASERX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HARTSFIELD CENTER PKWY STE 500
ATLANTA GA
30354-1377
US

IV. Provider business mailing address

100 HARTSFIELD CENTER PKWY STE 500
ATLANTA GA
30354-1377
US

V. Phone/Fax

Practice location:
  • Phone: 470-812-1097
  • Fax:
Mailing address:
  • Phone: 470-812-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: BRENDA LEMOINE
Title or Position: REGISTERED DIETITIAN/OWNER
Credential: RD,LDN
Phone: 470-812-1097