Healthcare Provider Details

I. General information

NPI: 1700190832
Provider Name (Legal Business Name): ELIZABETH BOYD ODOM RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 NORTH DOBBS STREET
HALIFAX NC
27839-0010
US

IV. Provider business mailing address

19 NORTH DOBBS STREET
HALIFAX NC
27839-0010
US

V. Phone/Fax

Practice location:
  • Phone: 252-583-5021
  • Fax: 252-583-2975
Mailing address:
  • Phone: 252-583-5021
  • Fax: 252-583-2975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberL001680
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number843319
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: