Healthcare Provider Details

I. General information

NPI: 1235247297
Provider Name (Legal Business Name): MARILYN BURTON KOWALCHUK RD, SCD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD STE 300
CHARLOTTE NC
28203-5863
US

IV. Provider business mailing address

PO BOX 60122
CHARLOTTE NC
28260-0122
US

V. Phone/Fax

Practice location:
  • Phone: 704-373-0212
  • Fax: 704-373-1216
Mailing address:
  • Phone: 704-373-0212
  • Fax: 704-373-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL000866
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: