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General NPI Number Information
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NPI Number | 1720684228
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Entity Type | Organization
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Legal Business Name | BEACHSIDE NUTRITION CONSULTANTS
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Dates
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Enumeration Date | 12/09/2020
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 414 2ND ST APT 330
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City | HERMOSA BEACH
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State | CA
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Zip | 90254-4610
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Country | US
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Telephone | 301-996-2927
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Fax |
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Provider Business Mailing Address
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Address Line | 29 ETHELWOOD CT
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City | OLNEY
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State | MD
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Zip | 20832-2900
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Country | US
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Telephone | 301-996-2927
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Fax |
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Authorized Official
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Title or Position | NUTRITIONIST
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Name | BROOKE AMELIA MADER
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Credential | MS, CNS, LDN
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Telephone | 301-996-2927
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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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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