Healthcare Provider Details

I. General information

NPI: 1649494196
Provider Name (Legal Business Name): LISA M BUCKLEY RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA M DEITCH

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PARK DR SUITE 145 NE ONCOLOGY ASSOCIATES
CONCORD NC
28025-2982
US

IV. Provider business mailing address

200 MEDICAL PARK DR SUITE 145 NE ONCOLOGY ASSOCIATES
CONCORD NC
28025-2982
US

V. Phone/Fax

Practice location:
  • Phone: 704-783-1370
  • Fax: 704-783-1389
Mailing address:
  • Phone: 704-783-1370
  • Fax: 704-783-1389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number925612
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: