Provider Demographics
NPI:1104532464
Name:CORE NUTRITION GROUP, INC.
Entity type:Organization
Organization Name:CORE NUTRITION GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:951-346-0064
Mailing Address - Street 1:29970 TECHNOLOGY DR STE 105D
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:299702 TECHNOLOGY DRIVE, SUITE 105-D
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563
Practice Address - Country:US
Practice Address - Phone:951-346-0064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty