MEDICARE: LAURA ROSE FUNCTIONAL NUTRITION

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1811853443
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAURA ROSE FUNCTIONAL NUTRITION

Provider Business Mailing Address
First Line	:	4751 MOUNT ROYAL LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-4690
Country	:	US
Telephone Number	:	607-743-6253
Fax Number	:	704-259-4120

Provider Business Practice Location Address
First Line	:	4751 MOUNT ROYAL LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-4690
Country	:	US
Telephone Number	:	607-743-6253
Fax Number	:	704-259-4120

Authorized Official
Title or Position	:	OWNER
Name	:	LAURA DRAGON
Credential	:	MS, RD, LDN
Telephone Number	:	607-743-6253

Provider Enumeration Date	:	12/29/2025
Last Update Date	:	12/29/2025

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