Healthcare Provider Details

I. General information

NPI: 1467599001
Provider Name (Legal Business Name): TOTAL NUTRITION TECHNOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 MALLARD CREEK RD STE 340
CHARLOTTE NC
28262-5203
US

IV. Provider business mailing address

10400 MALLARD CREEK RD STE 340
CHARLOTTE NC
28262-5203
US

V. Phone/Fax

Practice location:
  • Phone: 704-549-9550
  • Fax: 704-549-9570
Mailing address:
  • Phone: 704-549-9550
  • Fax: 704-549-9570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State

VIII. Authorized Official

Name: VANESSA LARA
Title or Position: CSO
Credential: PHD, CNS, LDN/LN
Phone: 704-549-9550