MEDICARE: MS. VICTORIA SHANTA RETELNY RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist		IL
2	133V00000X	Registered Dietitian		IL

General Provider Information

NPI Number	:	1780856526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICTORIA SHANTA RETELNY RD, LD

Provider Business Mailing Address
First Line	:	3024 N HAMILTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-8112
Country	:	US
Telephone Number	:	773-551-9882
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4208
Country	:	US
Telephone Number	:	773-551-9882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	04/01/2008

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