Healthcare Provider Details

I. General information

NPI: 1659940856
Provider Name (Legal Business Name): KELLEIGH GARLAND O'TOOLE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 BRAEBURN DR
SALEM VA
24153-7357
US

IV. Provider business mailing address

2515 RICHELIEU AVE SW
ROANOKE VA
24014-3323
US

V. Phone/Fax

Practice location:
  • Phone: 540-772-3620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86119227
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: