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General NPI Number Information
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NPI Number | 1801825534
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Entity Type | Organization
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Legal Business Name | REAL LIFE NUTRITION, INC.
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 03/22/2022
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Provider Practice Location Address
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Address Line | 5375 FALLOWATER LN
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City | ROANOKE
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State | VA
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Zip | 24018-2401
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Country | US
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Telephone | 540-797-0593
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Fax |
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Provider Business Mailing Address
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Address Line | 1802 ARLINGTON RD SW
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City | ROANOKE
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State | VA
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Zip | 24015-2808
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Country | US
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Telephone | 540-797-0593
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KATHERINE M SHAW
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Credential | R.D., C.D.E
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Telephone | 540-797-0593
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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 | 846139
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License Number State | VA
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