Healthcare Provider Details

I. General information

NPI: 1134368947
Provider Name (Legal Business Name): MY DIABETES DIETITIAN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S TRADE ST STE 107
MATTHEWS NC
28105-5767
US

IV. Provider business mailing address

12113 LANDEN DR
CHARLOTTE NC
28277-4664
US

V. Phone/Fax

Practice location:
  • Phone: 704-846-7105
  • Fax: 704-973-7732
Mailing address:
  • Phone: 704-846-7105
  • Fax: 704-973-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MS. JUDY E FISCHER
Title or Position: OWNER
Credential: RD, LDN, CDE
Phone: 704-846-7105