Healthcare Provider Details

I. General information

NPI: 1255013454
Provider Name (Legal Business Name): ILLA GARCIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 FISHBURNE ST
CHARLESTON SC
29403-4701
US

IV. Provider business mailing address

109 FISHBURNE ST
CHARLESTON SC
29403-4701
US

V. Phone/Fax

Practice location:
  • Phone: 336-247-1295
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberDT87709
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: