Healthcare Provider Details

I. General information

NPI: 1962978403
Provider Name (Legal Business Name): BARRY BRAGG CN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3607 FALLS RIVER AVE STE 111
RALEIGH NC
27614-7365
US

IV. Provider business mailing address

1167 SMITH CREEK WAY
WAKE FOREST NC
27587-7951
US

V. Phone/Fax

Practice location:
  • Phone: 919-614-4022
  • Fax:
Mailing address:
  • Phone: 919-614-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: