Provider Demographics
NPI:1689262362
Name:WATFORD, CALLI (RD)
Entity Type:Individual
Prefix:
First Name:CALLI
Middle Name:
Last Name:WATFORD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CALLI
Other - Middle Name:
Other - Last Name:DELTGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:1175 COOK RD STE 145
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8235
Practice Address - Country:US
Practice Address - Phone:803-395-3891
Practice Address - Fax:803-536-5220
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1770133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1770OtherLICENSE