Provider Demographics
NPI:1255003380
Name:MCMRD, LLC
Entity Type:Organization
Organization Name:MCMRD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD RDN
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSSELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:816-536-4236
Mailing Address - Street 1:11511 CRAGWOLD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-7013
Mailing Address - Country:US
Mailing Address - Phone:816-536-4236
Mailing Address - Fax:
Practice Address - Street 1:11511 CRAGWOLD RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-7013
Practice Address - Country:US
Practice Address - Phone:816-536-4236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1811274681OtherBCBS
MO1811274681Medicaid