Provider Demographics
NPI:1780456202
Name:THE QUEEN CITY DIETITIAN, LLC
Entity type:Organization
Organization Name:THE QUEEN CITY DIETITIAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERLOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, LDN
Authorized Official - Phone:704-564-9122
Mailing Address - Street 1:9325 FAIRCHILD LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-7822
Mailing Address - Country:US
Mailing Address - Phone:704-564-9122
Mailing Address - Fax:
Practice Address - Street 1:9325 FAIRCHILD LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-7822
Practice Address - Country:US
Practice Address - Phone:704-564-9122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty