Basic Information
| Provider Information | |||||||||
| NPI: | 1417134214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAK | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | CNSD, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417252 | ||||||||
| FaxNumber: | 5089416412 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089417252 | ||||||||
| FaxNumber: | 5089416412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 01/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1006X | 2187 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic |
No ID Information.