MEDICARE: PRANASPIRIT NUTRITION & WELLNESS, 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

General Provider Information

NPI Number	:	1710574322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRANASPIRIT NUTRITION & WELLNESS, LLC

Provider Business Mailing Address
First Line	:	2219 MAIN ST UNIT 249
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-2217
Country	:	US
Telephone Number	:	888-725-3135
Fax Number	:	877-259-1576

Provider Business Practice Location Address
First Line	:	2219 MAIN ST UNIT 249
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-2217
Country	:	US
Telephone Number	:	888-725-3135
Fax Number	:	877-259-1576

Authorized Official
Title or Position	:	OWNER
Name	:	MS. ILENE MICHELLE COHEN
Credential	:	MS, RDN, CDCES
Telephone Number	:	917-658-0554

Provider Enumeration Date	:	12/29/2020
Last Update Date	:	12/29/2020

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