Provider Demographics
NPI:1427376417
Name:STRACK, CARMEN RENEE (RD, LD, CNSD)
Entity type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:RENEE
Last Name:STRACK
Suffix:
Gender:F
Credentials:RD, LD, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST
Mailing Address - Street 2:SLOT # 547-01
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-6948
Mailing Address - Fax:501-296-1308
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:SLOT # 547-01
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-6948
Practice Address - Fax:501-296-1308
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR815133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered