Healthcare Provider Details

I. General information

NPI: 1942410725
Provider Name (Legal Business Name): PEAK NURITION AND WEIGHT LOSS CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 PEMBERTON HILL RD SUITE 101
APEX NC
27502-4266
US

IV. Provider business mailing address

1011 PEMBERTON HILL RD SUITE 101
APEX NC
27502-4266
US

V. Phone/Fax

Practice location:
  • Phone: 919-367-9355
  • Fax: 919-367-9276
Mailing address:
  • Phone: 919-367-9355
  • Fax: 919-367-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberL001396
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32989
License Number StateNC

VIII. Authorized Official

Name: DR. SAMUEL D. BLACKWELL
Title or Position: OWNER
Credential: M.D.
Phone: 919-367-9355