1861534364 NPI number — LAKE NORMAN NUTRITION ASSOCIATES, LLC

Table of content: (NPI 1861534364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861534364 NPI number — LAKE NORMAN NUTRITION ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE NORMAN NUTRITION ASSOCIATES, LLC
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:
LAKE NORMAN AND CHARLOTTE NUTRITION ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1861534364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19809 NORTHCOVE RD # B
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
CORNELIUS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28031-6445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-895-9865
Provider Business Mailing Address Fax Number:
704-895-9870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16501 NORTHCROSS DR STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28078-5040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-895-9865
Provider Business Practice Location Address Fax Number:
704-895-9870
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOOTEN
Authorized Official First Name:
CHRISTIN
Authorized Official Middle Name:
KIMBERLY
Authorized Official Title or Position:
DIETITIAN,DIABETES EDUCATOR
Authorized Official Telephone Number:
704-576-5001

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  L001079 , 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)





Copyright © 2007-2024 www.npivalidator.com