Provider Demographics
NPI:1417726001
Name:KIDNEY STONE DIETITIAN LLC
Entity Type:Organization
Organization Name:KIDNEY STONE DIETITIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPANY OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CINDEL
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:GWYN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:843-267-6549
Mailing Address - Street 1:220 ROSEBROOKS DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3609
Mailing Address - Country:US
Mailing Address - Phone:843-267-6549
Mailing Address - Fax:
Practice Address - Street 1:220 ROSEBROOKS DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-3609
Practice Address - Country:US
Practice Address - Phone:843-267-6549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-25
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered