Provider Demographics
NPI:1376881060
Name:MCCORMICK, KENNETH W (RD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:RD
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 287
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29602-0287
Mailing Address - Country:US
Mailing Address - Phone:864-751-3200
Mailing Address - Fax:864-751-3215
Practice Address - Street 1:975 W FARIS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4241
Practice Address - Country:US
Practice Address - Phone:864-729-8330
Practice Address - Fax:864-751-0479
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC849133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered