Healthcare Provider Details

I. General information

NPI: 1174441786
Provider Name (Legal Business Name): SYNERGETIC FUNCTIONAL NUTRITION & WELLNESS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 STEEPLE RDG CAMERON, NC 28326
CAMERON NC
28326-6615
US

IV. Provider business mailing address

238 STEEPLE RDG CAMERON, NC 28326
CAMERON NC
28326-6615
US

V. Phone/Fax

Practice location:
  • Phone: 808-634-1521
  • Fax: 472-215-8653
Mailing address:
  • Phone: 808-634-1521
  • Fax: 472-215-8653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GLADYS L ALICEA
Title or Position: CLINICAL NUTRITIONIST
Credential: CNS, LN
Phone: 808-634-1521