Healthcare Provider Details

I. General information

NPI: 1366069338
Provider Name (Legal Business Name): MINDFUL FORK NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/27/2020
Certification Date: 06/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 BURNET RD STE A
AUSTIN TX
78756-3317
US

IV. Provider business mailing address

1602 EDGEWOOD AVE
AUSTIN TX
78722-1935
US

V. Phone/Fax

Practice location:
  • Phone: 512-980-0590
  • Fax: 512-598-5306
Mailing address:
  • Phone: 512-980-0590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE AYOUB
Title or Position: OWNER
Credential: RDN, LD
Phone: 512-980-0590