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NPI Code Detail

MEDICARE: MAE PALINA CLARK RD

MEDICARE: MAE PALINA CLARK RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered DietitianD1275MS

General Provider Information

NPI Number : 1609117514
Entity Type Code : Individual
Provider Name (Legal Business Name) : MAE PALINA CLARK RD
Provider Business Mailing Address
First Line : 900 STARK RD
Second Line :
City : STARKVILLE
State : MS
Zip : 39759-3613
Country : US
Telephone Number : 662-323-4400
Fax Number : 662-323-4409
Provider Business Practice Location Address
First Line : 900 STARK RD
Second Line :
City : STARKVILLE
State : MS
Zip : 39759-3613
Country : US
Telephone Number : 662-323-4400
Fax Number : 662-323-4409
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/04/2013
Last Update Date : 03/04/2013

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Directions to “ MAE PALINA CLARK RD” Practice Location

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