Healthcare Provider Details

I. General information

NPI: 1972375673
Provider Name (Legal Business Name): PATH OF LIFE NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 OAK GROVE RD
BOONE NC
28607-7618
US

IV. Provider business mailing address

736 SHADOWBROOK DR
COLUMBIA SC
29210-3751
US

V. Phone/Fax

Practice location:
  • Phone: 803-575-0468
  • Fax: 803-728-3224
Mailing address:
  • Phone: 803-575-0468
  • Fax: 803-728-3224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JEREMY THOMAS PONDS
Title or Position: OWNER
Credential: MS, RDN, LD, IFNCP
Phone: 803-575-0468