Basic Information
| Provider Information | |||||||||
| NPI: | 1316296122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOLLUM | ||||||||
| FirstName: | RITHIRAT | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCOLLUM | ||||||||
| OtherFirstName: | RITHIRAT | ||||||||
| OtherMiddleName: | JOHN | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16236 W. TONTO ST. | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028297118 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 255 WEST BROWN RD. | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808333988 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2012 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3539 | AZ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.