Healthcare Provider Details

I. General information

NPI: 1184748741
Provider Name (Legal Business Name): MOLLY MCCOLLOUGH RD,LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4536 BARCLAY DR
ATLANTA GA
30338-5802
US

IV. Provider business mailing address

4536 BARCLAY DR
ATLANTA GA
30338-5802
US

V. Phone/Fax

Practice location:
  • Phone: 770-458-8711
  • Fax: 770-458-8640
Mailing address:
  • Phone: 770-458-8711
  • Fax: 770-458-8640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberLD002656
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: