Provider Demographics
NPI:1447985320
Name:GUT BRAIN BODY
Entity type:Organization
Organization Name:GUT BRAIN BODY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-897-2621
Mailing Address - Street 1:2048 OLIVER AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5568
Mailing Address - Country:US
Mailing Address - Phone:302-897-2621
Mailing Address - Fax:302-274-0071
Practice Address - Street 1:2048 OLIVER AVE APT A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5568
Practice Address - Country:US
Practice Address - Phone:302-897-2621
Practice Address - Fax:302-274-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-23
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty