Provider Demographics
NPI:1659667400
Name:MCCULLOCH, MARSHA (RD, LD)
Entity type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7717 W SNAPDRAGON ST
Mailing Address - Street 2:UNIT 4
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-5171
Mailing Address - Country:US
Mailing Address - Phone:605-906-1841
Mailing Address - Fax:
Practice Address - Street 1:7717 W SNAPDRAGON ST UNIT 4
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-5173
Practice Address - Country:US
Practice Address - Phone:605-906-1841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001860133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered