Provider Demographics
NPI:1053099143
Name:SURFSIDE NUTRITION, LLC
Entity type:Organization
Organization Name:SURFSIDE NUTRITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN
Authorized Official - Phone:805-263-7273
Mailing Address - Street 1:13 STANISLAUS AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1147
Mailing Address - Country:US
Mailing Address - Phone:805-263-7273
Mailing Address - Fax:888-885-3597
Practice Address - Street 1:13 STANISLAUS AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1147
Practice Address - Country:US
Practice Address - Phone:925-699-3002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-07
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty