Healthcare Provider Details

I. General information

NPI: 1134524341
Provider Name (Legal Business Name): MELISSA OMEGA MITCHELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5319 PARKSHIRE WAY
NORTH CHARLESTON SC
29418-2051
US

IV. Provider business mailing address

7073 MACKEY LN
HOLLYWOOD SC
29449-6289
US

V. Phone/Fax

Practice location:
  • Phone: 843-767-2121
  • Fax: 843-767-2102
Mailing address:
  • Phone: 843-323-7162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1041
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: