Healthcare Provider Details

I. General information

NPI: 1205379401
Provider Name (Legal Business Name): FRUITFUL NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 WINTERBERRY RIDGE DR
DURHAM NC
27713-9442
US

IV. Provider business mailing address

211 WINTERBERRY RIDGE DR
DURHAM NC
27713-9442
US

V. Phone/Fax

Practice location:
  • Phone: 574-276-0699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003347
License Number StateNC

VIII. Authorized Official

Name: RACHEL BORDOGNA
Title or Position: REGISTERED DIETITIAN
Credential:
Phone: 574-276-0699