Healthcare Provider Details

I. General information

NPI: 1568883759
Provider Name (Legal Business Name): FRUIT OF THE SPIRIT NUTRITION AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2013
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 GREENWICH RD SUITE 215
CHARLOTTE NC
28211-2355
US

IV. Provider business mailing address

5710 N OAKMONT ST
KANNAPOLIS NC
28081-6418
US

V. Phone/Fax

Practice location:
  • Phone: 704-785-1043
  • Fax:
Mailing address:
  • Phone: 704-785-1043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL00325
License Number StateNC

VIII. Authorized Official

Name: DONNA S GIBSON
Title or Position: REGISTERED DIETITIAN, NUTRITIONIST
Credential: RD, LDN
Phone: 704-785-1043