Healthcare Provider Details

I. General information

NPI: 1851053615
Provider Name (Legal Business Name): DESIGN YOUR BODY ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10208 BON AIRE DR
EL PASO TX
79924-2936
US

IV. Provider business mailing address

5076 SHELLBARK CT
GROVEPORT OH
43125-9398
US

V. Phone/Fax

Practice location:
  • Phone: 505-417-0036
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: CAILAH BROCK
Title or Position: FOUNDER
Credential: MS, CSCS, CPT, HC
Phone: 513-884-6741