Provider Demographics
NPI:1366977373
Name:SAMUEL-HODGE, CARMEN
Entity type:Individual
Prefix:PROF
First Name:CARMEN
Middle Name:
Last Name:SAMUEL-HODGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:CB # 7426
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-1965
Mailing Address - Country:US
Mailing Address - Phone:919-966-0360
Mailing Address - Fax:
Practice Address - Street 1:101 HUNT DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3497
Practice Address - Country:US
Practice Address - Phone:919-693-2141
Practice Address - Fax:919-693-8517
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004980133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered