Provider Demographics
NPI:1801218912
Name:MASK, CLAUDE III (RD)
Entity Type:Individual
Prefix:
First Name:CLAUDE
Middle Name:
Last Name:MASK
Suffix:III
Gender:M
Credentials:RD
Other - Prefix:MR
Other - First Name:CJ
Other - Middle Name:
Other - Last Name:MASK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:614 FLORENCE DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-5005
Mailing Address - Country:US
Mailing Address - Phone:706-616-2944
Mailing Address - Fax:
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-812-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003990133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered