Provider Demographics
NPI:1154961779
Name:PEGRAM, DANIEL (RD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:PEGRAM
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2529
Mailing Address - Country:US
Mailing Address - Phone:405-648-2121
Mailing Address - Fax:
Practice Address - Street 1:10400 MALLARD CREEK RD STE 340
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5203
Practice Address - Country:US
Practice Address - Phone:704-549-9550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-11
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86074561133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered