Healthcare Provider Details

I. General information

NPI: 1922693423
Provider Name (Legal Business Name): BACK 2 BASICS NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5216 CHAIRMANS CT STE 104
FREDERICK MD
21703-2858
US

IV. Provider business mailing address

2028 LIBERTY RD STE 103
ELDERSBURG MD
21784-5079
US

V. Phone/Fax

Practice location:
  • Phone: 410-598-4336
  • Fax: 443-280-6441
Mailing address:
  • Phone: 410-598-4336
  • Fax: 443-280-6441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: LINDSEY GILL CARTER
Title or Position: OWNER
Credential:
Phone: 410-598-4336