Provider Demographics
NPI:1316296122
Name:MCCOLLUM, RITHIRAT JOHN (COTA)
Entity type:Individual
Prefix:MR
First Name:RITHIRAT
Middle Name:JOHN
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:MR
Other - First Name:RITHIRAT
Other - Middle Name:JOHN
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:16236 W. TONTO ST.
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338
Mailing Address - Country:US
Mailing Address - Phone:602-829-7118
Mailing Address - Fax:
Practice Address - Street 1:255 WEST BROWN RD.
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:480-833-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3539314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility