Provider Demographics
NPI:1467470476
Name:PHILLIPS, MARY ALICE (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALICE
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 SPECHT POINT RD
Mailing Address - Street 2:STE 127
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-493-7878
Mailing Address - Fax:970-493-2682
Practice Address - Street 1:1600 SPECHT POINT RD
Practice Address - Street 2:STE 127
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-493-7878
Practice Address - Fax:970-493-2682
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC804733Medicare PIN