Provider Demographics
NPI:1306621032
Name:BALANCE NUTRITION WITH ANDI LLC
Entity type:Organization
Organization Name:BALANCE NUTRITION WITH ANDI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-688-1498
Mailing Address - Street 1:41810 N VENTURE DR UNIT C122
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41810 N VENTURE DR UNIT C122
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3172
Practice Address - Country:US
Practice Address - Phone:623-688-1498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty