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General NPI Number Information
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NPI Number | 1053029710
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Entity Type | Organization
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Legal Business Name | BEACH LIFE NUTRITION LLC
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Dates
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Enumeration Date | 11/11/2022
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Last Update Date | 11/11/2022
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Provider Practice Location Address
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Address Line | 2920 CAMARILLO LN
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City | VIRGINIA BEACH
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State | VA
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Zip | 23456-1558
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Country | US
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Telephone | 904-608-1068
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Fax |
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Provider Business Mailing Address
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Address Line | 2920 CAMARILLO LN
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City | VIRGINIA BEACH
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State | VA
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Zip | 23456-1558
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | RDN
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Name | JESSICA EDMONDS
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Credential |
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Telephone | 904-608-1068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State | NULL
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