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General NPI Number Information
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NPI Number | 1396138871
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Entity Type | Organization
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Legal Business Name | THOMAS C. PETRIE, C.D.N.
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Dates
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Enumeration Date | 03/09/2015
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Last Update Date | 03/09/2015
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Provider Practice Location Address
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Address Line | 20 WASHINGTON ST
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City | BALLSTON SPA
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State | NY
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Zip | 12020-1761
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Country | US
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Telephone | 518-879-5877
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Fax |
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Provider Business Mailing Address
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Address Line | 110 BROOKLINE RD APT. B-11
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City | BALLSTON SPA
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State | NY
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Zip | 12020-3527
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Country | US
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Telephone | 518-879-5877
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Fax |
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Authorized Official
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Title or Position | NUTRITIONIST
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Name | MR. THOMAS CHARLES PETRIE
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Credential | C.D.N.
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Telephone | 518-490-1720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 003560
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License Number State | NY
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