Provider Demographics
NPI:1245610534
Name:PATH OF LIFE NUTRITION
Entity Type:Organization
Organization Name:PATH OF LIFE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PONDS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, LD, IFNCP
Authorized Official - Phone:803-575-0468
Mailing Address - Street 1:736 SHADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-3751
Mailing Address - Country:US
Mailing Address - Phone:843-599-9046
Mailing Address - Fax:
Practice Address - Street 1:147 VERA RD STE A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3756
Practice Address - Country:US
Practice Address - Phone:803-575-0468
Practice Address - Fax:803-728-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8943Medicaid