Provider Demographics
NPI:1730807520
Name:BASAL NUTRITION LLC
Entity type:Organization
Organization Name:BASAL NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:FRISTED
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:714-955-3545
Mailing Address - Street 1:43020 BLACK DEER LOOP STE 206
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3406
Mailing Address - Country:US
Mailing Address - Phone:714-955-3545
Mailing Address - Fax:
Practice Address - Street 1:43020 BLACK DEER LOOP STE 206
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-3406
Practice Address - Country:US
Practice Address - Phone:951-238-7725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty