Healthcare Provider Details

I. General information

NPI: 1497395644
Provider Name (Legal Business Name): MACKENZIE MAE PEERY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3027 N CIRCLE DR
COLORADO SPRINGS CO
80909-1179
US

IV. Provider business mailing address

PO BOX 800022
KANSAS CITY MO
64180-0022
US

V. Phone/Fax

Practice location:
  • Phone: 719-776-3600
  • Fax: 719-776-3610
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: