Provider Demographics
NPI:1235247297
Name:KOWALCHUK, MARILYN BURTON (RD, SCD, LDN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:BURTON
Last Name:KOWALCHUK
Suffix:
Gender:F
Credentials:RD, SCD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60122
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0122
Mailing Address - Country:US
Mailing Address - Phone:704-373-0212
Mailing Address - Fax:704-373-1216
Practice Address - Street 1:1001 BLYTHE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5863
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:704-373-1216
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000866133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2993632AMedicare PIN