Healthcare Provider Details

I. General information

NPI: 1700165255
Provider Name (Legal Business Name): KEVIN PATRICK MCCORMICK NUTRITIONIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 E CORRINE DR. SUITE 1
PHOENIX AZ
85032
US

IV. Provider business mailing address

2702 E CORRINE DR
PHOENIX AZ
85032-6942
US

V. Phone/Fax

Practice location:
  • Phone: 602-348-1004
  • Fax:
Mailing address:
  • Phone: 602-348-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: