Provider Demographics
NPI:1144644139
Name:DEAL, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DEAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HEALTH WAY DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1420
Mailing Address - Country:US
Mailing Address - Phone:573-438-5451
Mailing Address - Fax:573-438-5460
Practice Address - Street 1:300 HEALTH WAY DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1420
Practice Address - Country:US
Practice Address - Phone:573-438-5451
Practice Address - Fax:573-438-5460
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1001011692133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2001011692OtherLICENSED DIETITIAN