Healthcare Provider Details

I. General information

NPI: 1922648930
Provider Name (Legal Business Name): KG HEALTHY LIFESTYLES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 DALLAS PKWY STE 115
PLANO TX
75093-4305
US

IV. Provider business mailing address

2100 DALLAS PKWY STE 115
PLANO TX
75093-4305
US

V. Phone/Fax

Practice location:
  • Phone: 469-409-0156
  • Fax:
Mailing address:
  • Phone: 469-409-0156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: KANDI SUZANNE ALYOUSEF
Title or Position: OWNER
Credential:
Phone: 972-213-6201