MEDICARE: HAIKU NUTRITIONAL EMPOWERMENT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124790811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAIKU NUTRITIONAL EMPOWERMENT LLC

Provider Business Mailing Address
First Line	:	15212 N 2ND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-3610
Country	:	US
Telephone Number	:	602-935-8791
Fax Number	:

Provider Business Practice Location Address
First Line	:	15212 N 2ND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-3610
Country	:	US
Telephone Number	:	602-935-8791
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. KELLY RENEE ROBERS
Credential	:	RDN, CDCES
Telephone Number	:	602-935-8791

Provider Enumeration Date	:	09/30/2021
Last Update Date	:	09/30/2021

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Directions to “HAIKU NUTRITIONAL EMPOWERMENT LLC ” Practice Location

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