Provider Demographics
NPI:1760675052
Name:VINCENT, PETER (RD,LDN)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:VINCENT
Suffix:
Gender:M
Credentials:RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WACCAMAW
Mailing Address - State:NC
Mailing Address - Zip Code:28450-2107
Mailing Address - Country:US
Mailing Address - Phone:910-232-0562
Mailing Address - Fax:
Practice Address - Street 1:2029 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6600
Practice Address - Country:US
Practice Address - Phone:910-798-6674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00954165133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered