Provider Demographics
NPI:1619606571
Name:NUTRIBLE INC
Entity type:Organization
Organization Name:NUTRIBLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KWAMANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:JD, RN
Authorized Official - Phone:708-502-2828
Mailing Address - Street 1:2416 SPECTRUM
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3138
Mailing Address - Country:US
Mailing Address - Phone:708-502-2828
Mailing Address - Fax:
Practice Address - Street 1:2416 SPECTRUM
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3138
Practice Address - Country:US
Practice Address - Phone:708-502-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-07
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty