Healthcare Provider Details

I. General information

NPI: 1851390678
Provider Name (Legal Business Name): ANU RAMGOOLAM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 OHIO AVE
CLARKSDALE MS
38614-7200
US

IV. Provider business mailing address

510 HIGHWAY 322
CLARKSDALE MS
38614-4717
US

V. Phone/Fax

Practice location:
  • Phone: 662-624-2504
  • Fax: 662-627-3629
Mailing address:
  • Phone: 662-624-4292
  • Fax: 662-624-4354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1077
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: