Healthcare Provider Details

I. General information

NPI: 1578201950
Provider Name (Legal Business Name): NUTRITION IAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 S JEFFORDS ST
FLORENCE SC
29506-3129
US

IV. Provider business mailing address

417 S JEFFORDS ST
FLORENCE SC
29506-3129
US

V. Phone/Fax

Practice location:
  • Phone: 706-627-5864
  • Fax:
Mailing address:
  • Phone: 706-627-5864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. IRIS ABIGIAL MCDUFFIE
Title or Position: REGISTERED DIETITIAN NUTRITIONIST
Credential: RDN
Phone: 706-627-5864