Healthcare Provider Details

I. General information

NPI: 1972119873
Provider Name (Legal Business Name): ERIC TUCKER RD LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 09/17/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 DISCOVERY DR STE 125
RALEIGH NC
27616-1905
US

IV. Provider business mailing address

5208 WALLINGFORD DR
RALEIGH NC
27616-7817
US

V. Phone/Fax

Practice location:
  • Phone: 770-403-4112
  • Fax:
Mailing address:
  • Phone: 770-403-4112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberL006231
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License NumberL006231
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL006231
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: