Provider Demographics
NPI:1336452390
Name:PEAK NUTRITION AND WEIGHT LOSS CLINIC, P.A.
Entity Type:Organization
Organization Name:PEAK NUTRITION AND WEIGHT LOSS CLINIC, P.A.
Other - Org Name:PEAK NUTRITION AND WEIGHT LOSS CLINIC HOLLY SPRINGS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
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:919-586-0031
Mailing Address - Street 1:216 VILLAGE WALK DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7681
Mailing Address - Country:US
Mailing Address - Phone:919-586-0031
Mailing Address - Fax:919-586-0035
Practice Address - Street 1:216 VILLAGE WALK DR
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-7681
Practice Address - Country:US
Practice Address - Phone:919-586-0031
Practice Address - Fax:919-586-0035
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK NUTRITION AND WEIGHT LOSS CLINIC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32989207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty