1497107684 NPI number — CAROLINA NUTRITION SPECIALISTS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497107684 NPI number — CAROLINA NUTRITION SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA NUTRITION SPECIALISTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497107684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7124 EASTRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APEX
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27539-6822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-215-7609
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 N WEST ST
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27603-1399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-215-7609
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MIKOLAJEWSKI
Authorized Official First Name:
BETSY
Authorized Official Middle Name:
COVINGTON
Authorized Official Title or Position:
CO-OWNER, NUTRITIONIST
Authorized Official Telephone Number:
919-215-7609

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  001101 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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