Basic Information
| Provider Information | |||||||||
| NPI: | 1316403595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HAWTHORN PKWY STE 235 | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 6100 WESTERN PL STE 908 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761074600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177517802 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT85837 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.