Healthcare Provider Details

I. General information

NPI: 1164130506
Provider Name (Legal Business Name): LAUREN ASHLEY ZIDEK RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 OKATIE CENTER BLVD
OKATIE SC
29909
US

IV. Provider business mailing address

PO BOX 1945
WILMINGTON NC
28402-1945
US

V. Phone/Fax

Practice location:
  • Phone: 843-706-8660
  • Fax:
Mailing address:
  • Phone: 910-341-4556
  • Fax: 866-363-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2549
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: