Basic Information
| Provider Information | |||||||||
| NPI: | 1871973396 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DURHAM LIFESTYLE MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5324 MCFARLAND RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277076865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193547077 | ||||||||
| FaxNumber: | 9193547075 | ||||||||
| Practice Location | |||||||||
| Address1: | 5324 MCFARLAND RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277076865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193547077 | ||||||||
| FaxNumber: | 9193547075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9192608423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.