Healthcare Provider Details

I. General information

NPI: 1083017222
Provider Name (Legal Business Name): MAKALA KATUSCAK SMITH RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK RD STE LL9
COLUMBIA SC
29203-6875
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-9660
  • Fax: 803-434-9669
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1235
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: