MEDICARE: NOURISH, INC.

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

General Provider Information

NPI Number	:	1710544275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOURISH, INC.

Provider Business Mailing Address
First Line	:	NOURISH
Second Line	:	130 WALNUT AVENUE
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-3835
Country	:	US
Telephone Number	:	831-359-5335
Fax Number	:	866-731-7132

Provider Business Practice Location Address
First Line	:	NOURISH
Second Line	:	130 WALNUT AVENUE
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-3835
Country	:	US
Telephone Number	:	831-359-5335
Fax Number	:	866-731-7132

Authorized Official
Title or Position	:	REGISTERED DIETITIAN,CEO, PRESIDENT
Name	:	MRS. JOCELYN VAUGHNES DUBIN
Credential	:	MS, RD
Telephone Number	:	831-359-0675

Provider Enumeration Date	:	05/21/2019
Last Update Date	:	05/21/2019

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