Provider Demographics
NPI:1063086064
Name:MAUI NUTRITION THERAPY LLC
Entity type:Organization
Organization Name:MAUI NUTRITION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:G
Authorized Official - Last Name:DE ROODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-269-9633
Mailing Address - Street 1:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-1147
Mailing Address - Country:US
Mailing Address - Phone:808-269-9633
Mailing Address - Fax:808-862-6520
Practice Address - Street 1:17732 HALEAKALA HWY
Practice Address - Street 2:
Practice Address - City:KULA
Practice Address - State:HI
Practice Address - Zip Code:96790-8036
Practice Address - Country:US
Practice Address - Phone:808-269-9633
Practice Address - Fax:808-862-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty