MEDICARE: LISA OLIVER NUTRITION THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist
2	133NN1002X	Nutrition Education Nutritionist

General Provider Information

NPI Number	:	1073919668
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA OLIVER NUTRITION THERAPIST

Provider Business Mailing Address
First Line	:	3225 GROVESHIRE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8391
Country	:	US
Telephone Number	:	888-238-4078
Fax Number	:

Provider Business Practice Location Address
First Line	:	1417 GREGG ST
Second Line	:	SUITE1
City	:	COLUMBIA
State	:	SC
Zip	:	29201-3527
Country	:	US
Telephone Number	:	888-238-4078
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2014
Last Update Date	:	11/10/2014

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