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General NPI Number Information
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NPI Number | 1336452390
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Entity Type | Organization
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Legal Business Name | PEAK NUTRITION AND WEIGHT LOSS CLINIC, P.A.
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Dates
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Enumeration Date | 07/20/2010
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Last Update Date | 07/20/2010
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Provider Practice Location Address
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Address Line | 216 VILLAGE WALK DR
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540-7681
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Country | US
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Telephone | 919-586-0031
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Fax | 919-586-0035
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Provider Business Mailing Address
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Address Line | 216 VILLAGE WALK DR
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540-7681
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Country | US
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Telephone | 919-586-0031
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Fax | 919-586-0035
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Authorized Official
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Title or Position | OWNER/MEDICAL DIRECTOR
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Name | DR. SAMUEL D BLACKWELL
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Credential | M.D.
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Telephone | 919-586-0031
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QB0002X
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Taxonomy Name | Obesity Medicine (Family Medicine) Physician
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License Number | 32989
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License Number State | NC
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