Provider Demographics
NPI:1669016804
Name:DECARO, MICHAEL (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DECARO
Suffix:
Gender:M
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 WILLOW RUN RD APT 2A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0116
Mailing Address - Country:US
Mailing Address - Phone:704-608-9351
Mailing Address - Fax:
Practice Address - Street 1:309 S SHARON AMITY RD STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2978
Practice Address - Country:US
Practice Address - Phone:704-926-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered