Provider Demographics
NPI:1942410725
Name:PEAK NURITION AND WEIGHT LOSS CLINIC PA
Entity Type:Organization
Organization Name:PEAK NURITION AND WEIGHT LOSS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-367-9355
Mailing Address - Street 1:1011 PEMBERTON HILL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-4266
Mailing Address - Country:US
Mailing Address - Phone:919-367-9355
Mailing Address - Fax:919-367-9276
Practice Address - Street 1:1011 PEMBERTON HILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-4266
Practice Address - Country:US
Practice Address - Phone:919-367-9355
Practice Address - Fax:919-367-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001396133VN1006X
NC32989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty