Basic Information
| Provider Information | |||||||||
| NPI: | 1255984472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRICE | ||||||||
| FirstName: | CALLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7731 OLD CANTON RD STE B | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014990935 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 BAPTIST DR STE 301 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391102012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014990935 | ||||||||
| FaxNumber: | 6014990936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2019 | ||||||||
| LastUpdateDate: | 12/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 01527231 | 05 | MS | MEDICAID |