Provider Demographics
NPI:1629429824
Name:REAL FOOD CHARLOTTE, INC.
Entity Type:Organization
Organization Name:REAL FOOD CHARLOTTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:T
Authorized Official - Last Name:HABECKER
Authorized Official - Suffix:
Authorized Official - Credentials:RD,LDN
Authorized Official - Phone:407-408-7242
Mailing Address - Street 1:5501 HOLYOKE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-6898
Mailing Address - Country:US
Mailing Address - Phone:407-408-7242
Mailing Address - Fax:
Practice Address - Street 1:6135 PARK SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3272
Practice Address - Country:US
Practice Address - Phone:407-408-7242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003989133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1053664383OtherNPPES
NCDT1060Medicaid