=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043675259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLIE GEER ROBERTS RD, LDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2015
-----------------------------------------------------
Last Update Date | 12/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7810 BALLANTYNE COMMONS PKWY SUITE 200
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-995-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13625 FIRENZA CIR APARTMENT 104
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28273-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-276-2171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | L004796
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------