Healthcare Provider Details

I. General information

NPI: 1841623097
Provider Name (Legal Business Name): CIRCLE OF LIFE NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 STONECROFT CT
WINSTON SALEM NC
27103-6095
US

IV. Provider business mailing address

1410 STONECROFT CT
WINSTON SALEM NC
27103-6095
US

V. Phone/Fax

Practice location:
  • Phone: 336-420-9567
  • Fax:
Mailing address:
  • Phone: 336-420-9567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberL002793
License Number StateNC

VIII. Authorized Official

Name: JENNIFER ELIZABETH AHMED
Title or Position: NUTRITIONIST
Credential: RD, LDN
Phone: 336-420-9567