Healthcare Provider Details

I. General information

NPI: 1740330794
Provider Name (Legal Business Name): MARY J. MCMILLION CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 12/01/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 ALEXANDER STREET
CEDAR GROVE WV
25039
US

IV. Provider business mailing address

PO BOX 1680
HUNTINGTON WV
25717-1680
US

V. Phone/Fax

Practice location:
  • Phone: 304-595-1770
  • Fax: 304-595-3298
Mailing address:
  • Phone: 304-697-1396
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number235
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: