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General NPI Number Information
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NPI Number | 1528667623
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Entity Type | Organization
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Legal Business Name | THE SIMPLE LEAF, LLC
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Dates
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Enumeration Date | 10/20/2020
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Last Update Date | 10/20/2020
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Provider Practice Location Address
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Address Line | 4824 CRANER AVE APT 214
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91601-5133
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Country | US
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Telephone | 424-259-0993
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5145
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City | CRESTLINE
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State | CA
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Zip | 92325-5145
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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 | OWNER
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Name | BRYNA GAVIN
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Credential | CNS
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Telephone | 424-259-0993
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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 |
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License Number State |
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