=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780111401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIABETES AND NUTRITION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2017
-----------------------------------------------------
Last Update Date | 05/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75-184 HUALALAI RD STE 203
-----------------------------------------------------
City | KAILUA KONA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96740-1719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-329-9211
-----------------------------------------------------
Fax | 808-329-0009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4787
-----------------------------------------------------
City | KAILUA KONA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96745-4787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-345-6919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RD, CDE
-----------------------------------------------------
Name | TERRI L RYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-345-6919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 836581
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------