Healthcare Provider Details

I. General information

NPI: 1780402065
Provider Name (Legal Business Name): CARMEN REBECCA CUCALON RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 DUKE MEDICINE CIRCLE, ROOM 015 PURPLE ZONE
DURHAM NC
27710
US

IV. Provider business mailing address

704 15TH ST APT 222
DURHAM NC
27705-3970
US

V. Phone/Fax

Practice location:
  • Phone: 919-668-2290
  • Fax:
Mailing address:
  • Phone: 401-284-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL007415
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: