Healthcare Provider Details

I. General information

NPI: 1538768577
Provider Name (Legal Business Name): CUSTOM NUTRITION & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

594 CENTENNIAL DR
CULLOWHEE NC
28723-1589
US

IV. Provider business mailing address

745 HOLLY HILLS RD
SYLVA NC
28779-6964
US

V. Phone/Fax

Practice location:
  • Phone: 828-330-9903
  • Fax: 833-492-5875
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KRYSTLE T HOLT
Title or Position: OWNER
Credential: MHS RDN LDN ACSM-CPT
Phone: 910-231-7589