Provider Demographics
NPI:1497046601
Name:GORE, BEVERLY (RD, LDN)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 W CORNELIUS HARNETT BLVD
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-9335
Mailing Address - Country:US
Mailing Address - Phone:910-814-6240
Mailing Address - Fax:910-893-9429
Practice Address - Street 1:307 W CORNELIUS HARNETT BLVD
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-9335
Practice Address - Country:US
Practice Address - Phone:910-814-6240
Practice Address - Fax:910-893-9429
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC3404343Medicaid
NC07212OtherBCBS
NC155383938OtherTRICARE
NC183296OtherMEDCOST
NC34D0864770OtherCLIA
NC2803708Medicare Oscar/Certification