1316637812 NPI number — BE SQUARED NUTRITION LLC

Table of content: (NPI 1316637812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316637812 NPI number — BE SQUARED NUTRITION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BE SQUARED NUTRITION LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316637812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 PARK ST STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTESVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22902-4769
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-234-4591
Provider Business Mailing Address Fax Number:
855-955-3898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 PARK ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22902-4769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-234-4591
Provider Business Practice Location Address Fax Number:
855-955-3898
Provider Enumeration Date:
05/09/2023

Additional Information

Authorized Official

Authorized Official Last Name:
BLALOCK
Authorized Official First Name:
BETHANY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
434-234-4591

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133VN1004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 86012192 . This is a "COMMISSION ON DIETETIC REGISTRATION" identifier . This identifiers is of the category "OTHER".




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