Healthcare Provider Details

I. General information

NPI: 1366636557
Provider Name (Legal Business Name): MARTHA JANE COLLINS RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E COLLEGE DR
COLBY KS
67701-3702
US

IV. Provider business mailing address

100 E COLLEGE DR
COLBY KS
67701-3702
US

V. Phone/Fax

Practice location:
  • Phone: 785-460-8489
  • Fax: 785-460-4870
Mailing address:
  • Phone: 785-460-8489
  • Fax: 785-460-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number835
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: