Healthcare Provider Details

I. General information

NPI: 1023281144
Provider Name (Legal Business Name): CECILIA KENNEDY MCMILLAN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 ASHLEY AVE SUITE EH1108
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

165 ASHLEY AVE SUITE EH1108, PO BOX 250905
CHARLESTON SC
29425-8905
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-9774
  • Fax:
Mailing address:
  • Phone: 843-792-9774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: