Provider Demographics
NPI:1306329990
Name:CHARLOTTE NUTRITION LLC
Entity type:Organization
Organization Name:CHARLOTTE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL, MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:BLACK
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:980-224-3514
Mailing Address - Street 1:5821 FAIRVIEW ROAD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209
Mailing Address - Country:US
Mailing Address - Phone:980-224-3514
Mailing Address - Fax:704-343-6549
Practice Address - Street 1:5821 FAIRVIEW ROAD
Practice Address - Street 2:SUITE 216
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:980-224-3514
Practice Address - Fax:704-343-6549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty