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General NPI Number Information
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NPI Number | 1730638164
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Entity Type | Individual
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Provider Name | MARIE COLLINS CUSTEAD
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Gender | Female
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Dates
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Enumeration Date | 09/27/2016
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Last Update Date | 09/27/2016
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Provider Practice Location Address
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Address Line | SFA ATHLETIC FIELDHOUSE 712 HAYTER ST
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City | NACOGDOCHES
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State | TX
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Zip | 75962-0001
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Country | US
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Telephone | 936-468-3506
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Fax | 936-468-4052
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Provider Business Mailing Address
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Address Line | SFA ATHLETIC FIELDHOUSE 712 HAYTER ST
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City | NACOGDOCHES
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State | TX
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Zip | 75962-0001
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Country | US
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Telephone | 936-468-3506
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Fax | 936-468-4052
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | DT84467
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License Number State | TX
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