Healthcare Provider Details

I. General information

NPI: 1780518530
Provider Name (Legal Business Name): PURE BALANCE CANCER SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 N CYPRESS WAY
LEHI UT
84048-5831
US

IV. Provider business mailing address

2630 N CYPRESS WAY
LEHI UT
84048-5831
US

V. Phone/Fax

Practice location:
  • Phone: 252-202-7594
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: NIK IGNJATOVIC
Title or Position: CO-OWNER
Credential:
Phone: 801-558-9174