Provider Demographics
NPI:1578803771
Name:POPOVICH, TIMOTHY LEE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEE
Last Name:POPOVICH
Suffix:
Gender:M
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03302-1806
Mailing Address - Country:US
Mailing Address - Phone:603-271-2283
Mailing Address - Fax:
Practice Address - Street 1:105 PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03302-1806
Practice Address - Country:US
Practice Address - Phone:603-271-2283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH874147133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered