Healthcare Provider Details

I. General information

NPI: 1891767356
Provider Name (Legal Business Name): MELANIE JO CRAIG RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FORT CARSON CO
80913-4603
US

IV. Provider business mailing address

245 ELLSWORTH ST
COLORADO SPRINGS CO
80906-7979
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7968
  • Fax: 719-526-7586
Mailing address:
  • Phone: 719-526-7968
  • Fax: 719-526-7586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT03155
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: