Provider Demographics
NPI:1487027793
Name:BEREFORD, LYNAE
Entity Type:Individual
Prefix:
First Name:LYNAE
Middle Name:
Last Name:BEREFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 WALTERS LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-2339
Mailing Address - Country:US
Mailing Address - Phone:803-608-4748
Mailing Address - Fax:
Practice Address - Street 1:830 WALTERS LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-2339
Practice Address - Country:US
Practice Address - Phone:803-608-4748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1218133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered