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General NPI Number Information
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NPI Number | 1811553555
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Entity Type | Organization
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Legal Business Name | DIET OF A LIFETIME, LLC
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Dates
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Enumeration Date | 05/17/2019
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Last Update Date | 05/17/2019
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Provider Practice Location Address
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Address Line | 123 S PINE ST
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City | PINE BLUFF
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State | AR
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Zip | 71601-4222
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Country | US
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Telephone | 870-540-9114
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Fax |
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Provider Business Mailing Address
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Address Line | 420 SANDY BAYOU LN
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City | PINE BLUFF
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State | AR
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Zip | 71603-6555
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Country | US
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Telephone | 870-850-0351
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Fax | 870-850-0351
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Authorized Official
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Title or Position | OWNER
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Name | DEBRA C GOLDMON
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Credential |
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Telephone | 870-540-9114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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