Basic Information
| Provider Information | |||||||||
| NPI: | 1962548057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKS | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 ENTERPRISE BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644540888 | ||||||||
| FaxNumber: | 8644541130 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 W FARIS RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644554003 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 133V00000X | 537217 | SC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | P00021522 | 01 | SC | MEDICARE RAILROAD ID | OTHER |