Provider Demographics
NPI:1205477858
Name:CHARLOTTE DIETITIANS LLC
Entity type:Organization
Organization Name:CHARLOTTE DIETITIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORRIE
Authorized Official - Middle Name:DARCY
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD/N
Authorized Official - Phone:561-603-1779
Mailing Address - Street 1:2643 BRIGHTMOOR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-2433
Mailing Address - Country:US
Mailing Address - Phone:561-603-1779
Mailing Address - Fax:
Practice Address - Street 1:1212 MANN DR STE 100
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5511
Practice Address - Country:US
Practice Address - Phone:561-603-1779
Practice Address - Fax:704-839-2335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-04
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1922351469OtherBLUE CROSS BLUE SHIELD OF NORTH CAROLINA