Healthcare Provider Details

I. General information

NPI: 1114709573
Provider Name (Legal Business Name): BALANCED BITES NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 S EAGLE RD STE 205
EAGLE ID
83616-6079
US

IV. Provider business mailing address

408 S EAGLE RD STE 205
EAGLE ID
83616-6079
US

V. Phone/Fax

Practice location:
  • Phone: 208-954-0862
  • Fax: 208-668-8871
Mailing address:
  • Phone: 208-954-0862
  • Fax: 208-668-8871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TRACY BENTO
Title or Position: REGISTERED DIETITIAN
Credential: RD, CDCES, CSOWM
Phone: 208-954-0862