Provider Demographics
NPI:1700165255
Name:MCCORMICK, KEVIN PATRICK (NUTRITIONIST)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PATRICK
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 E CORRINE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-6942
Mailing Address - Country:US
Mailing Address - Phone:602-348-1004
Mailing Address - Fax:
Practice Address - Street 1:2702 E CORRINE DR. SUITE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-348-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education