Provider Demographics
NPI:1649868274
Name:HIDOCK, LEA BOYLE
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:BOYLE
Last Name:HIDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:RUTH
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:322 LAMAR AVE.
Mailing Address - Street 2:STE 107 #1061
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204
Mailing Address - Country:US
Mailing Address - Phone:704-288-7133
Mailing Address - Fax:
Practice Address - Street 1:1900 E GOLF RD STE 905
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-5834
Practice Address - Country:US
Practice Address - Phone:847-558-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002840133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty