Healthcare Provider Details

I. General information

NPI: 1710971940
Provider Name (Legal Business Name): KENYA LATRICA MCCANT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122A GORDON COMMERCIAL DR
LAGRANGE GA
30240-5740
US

IV. Provider business mailing address

6300 MOSELEY DIXON RD APT. 202P
MACON GA
31220-8400
US

V. Phone/Fax

Practice location:
  • Phone: 706-845-4035
  • Fax: 706-845-4309
Mailing address:
  • Phone: 478-475-0423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002906
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: