Healthcare Provider Details

I. General information

NPI: 1841395068
Provider Name (Legal Business Name): CHANDRA BIVENS CARTY R.D.,L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 ROCK QUARRY RD
STOCKBRIDGE GA
30281-5047
US

IV. Provider business mailing address

2605 BRUSHY NOB LN
STOCKBRIDGE GA
30281-5243
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-0836
  • Fax: 770-389-0886
Mailing address:
  • Phone: 770-389-0836
  • Fax: 770-389-0886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD000618
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLD000618
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD000618
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: