Provider Demographics
NPI:1164857231
Name:LG NUTRITION LLC
Entity Type:Organization
Organization Name:LG NUTRITION LLC
Other - Org Name:SUMMERFIELD CUSTOM WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GREENHOW BRANSFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-663-5166
Mailing Address - Street 1:8801 FAST PARK DR STE 213
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4853
Mailing Address - Country:US
Mailing Address - Phone:919-442-8398
Mailing Address - Fax:888-856-3502
Practice Address - Street 1:1209 MARKET ST
Practice Address - Street 2:SUITE J
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4345
Practice Address - Country:US
Practice Address - Phone:910-663-5166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004173133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty