Healthcare Provider Details

I. General information

NPI: 1316637812
Provider Name (Legal Business Name): BE SQUARED NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 PARK ST STE C
CHARLOTTESVILLE VA
22902-4769
US

IV. Provider business mailing address

515 PARK ST STE C
CHARLOTTESVILLE VA
22902-4769
US

V. Phone/Fax

Practice location:
  • Phone: 434-234-4591
  • Fax: 855-955-3898
Mailing address:
  • Phone: 434-234-4591
  • Fax: 855-955-3898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. BETHANY BLALOCK
Title or Position: OWNER
Credential: RDN
Phone: 434-234-4591