Healthcare Provider Details

I. General information

NPI: 1053029710
Provider Name (Legal Business Name): BEACH LIFE NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 CAMARILLO LN
VIRGINIA BEACH VA
23456-1558
US

IV. Provider business mailing address

2920 CAMARILLO LN
VIRGINIA BEACH VA
23456-1558
US

V. Phone/Fax

Practice location:
  • Phone: 904-608-1068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSICA EDMONDS
Title or Position: RDN
Credential:
Phone: 904-608-1068