1699803528 NPI number — MS. CAROL GREEN FENWICK RD, LD

Table of content: MS. CAROL GREEN FENWICK RD, LD (NPI 1699803528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699803528 NPI number — MS. CAROL GREEN FENWICK RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENWICK
Provider First Name:
CAROL
Provider Middle Name:
GREEN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
Provider Gender Code:
F

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:
1699803528
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1514 MATHIS FERRY RD
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464-9728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-670-1997
Provider Business Mailing Address Fax Number:
843-388-0117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1514 MATHIS FERRY RD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-9728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-670-1997
Provider Business Practice Location Address Fax Number:
843-388-0117
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 674 . This is a "DIETETICS PRACTICE LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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