Provider Demographics
NPI:1184025694
Name:SCALLON, TIMOTHY (MS RD LD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SCALLON
Suffix:
Gender:M
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 COUNTY ROAD 2322
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-8823
Mailing Address - Country:US
Mailing Address - Phone:936-552-4873
Mailing Address - Fax:
Practice Address - Street 1:231 COUNTY ROAD 2322
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-8823
Practice Address - Country:US
Practice Address - Phone:936-552-4873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT00726133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered