Healthcare Provider Details

I. General information

NPI: 1497994172
Provider Name (Legal Business Name): NORTH MOUNTAIN DIETETIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8006 SENEDO RD
MOUNT JACKSON VA
22842-2232
US

IV. Provider business mailing address

8006 SENEDO RD
MOUNT JACKSON VA
22842-2232
US

V. Phone/Fax

Practice location:
  • Phone: 540-477-4292
  • Fax:
Mailing address:
  • Phone: 540-477-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: SHARON S. CLARK
Title or Position: REGISTERED DIETITIAN
Credential: R.D.
Phone: 540-331-5050