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General NPI Number Information
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NPI Number | 1306334578
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Entity Type | Organization
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Legal Business Name | SEASIDE NUTRITION LLC
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Dates
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Enumeration Date | 04/24/2018
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Last Update Date | 04/24/2018
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Provider Practice Location Address
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Address Line | 133 MOHEGAN RD
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6023
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Country | US
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Telephone | 904-540-2503
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1568
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32085-1568
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Country | US
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Telephone | 904-540-2503
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KERI BOMARITO
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Credential | RD, LD/N
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Telephone | 904-540-2503
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number | ND7315
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 86032198
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License Number State | FL
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