Healthcare Provider Details

I. General information

NPI: 1063247567
Provider Name (Legal Business Name): MOLLIE CAROLINE MCCONAHAY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLIE CAROLINE LEWIS RD, LD

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 ASHLEY AVE RM 318
CHARLESTON SC
29425-8907
US

IV. Provider business mailing address

1337 FORT JOHNSON RD APT B
CHARLESTON SC
29412-8836
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-5062
  • Fax:
Mailing address:
  • Phone: 567-203-2614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLRD.2209
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: