Provider Demographics
NPI:1487260287
Name:NUTRITION SUPPORT CLINIC
Entity type:Organization
Organization Name:NUTRITION SUPPORT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:X
Authorized Official - Last Name:LIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CEDRD-S
Authorized Official - Phone:650-308-8226
Mailing Address - Street 1:20 HAROLD AVE STE C4
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-2067
Mailing Address - Country:US
Mailing Address - Phone:650-308-8226
Mailing Address - Fax:844-543-8849
Practice Address - Street 1:20 HAROLD AVE STE C4
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-2067
Practice Address - Country:US
Practice Address - Phone:650-308-8226
Practice Address - Fax:844-543-8849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty