=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255003380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCMRD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2021
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10805 SUNSET OFFICE DR STE 300
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63127-1027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-470-4422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11511 CRAGWOLD RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-536-4236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD RDN
-----------------------------------------------------
Name | MELINDA MUSSELMAN
-----------------------------------------------------
Credential | RDN
-----------------------------------------------------
Telephone | 816-536-4236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------