Healthcare Provider Details

I. General information

NPI: 1154013696
Provider Name (Legal Business Name): PARKER CHARLES LANE RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E BROAD ST
RICHMOND VA
23298-5025
US

IV. Provider business mailing address

PO BOX 19171
PHILADELPHIA PA
19171-8997
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-0970
  • Fax: 804-628-0204
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 NumberLDN6548
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86170171
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: