Basic Information
| Provider Information | |||||||||
| NPI: | 1407855034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W 27TH ST | ||||||||
| Address2: | ATTN: WILLIAM J GUTEKUNST | ||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4300 FAYETTEVILLE RD | ||||||||
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| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106715830 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L000588 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.