Healthcare Provider Details

I. General information

NPI: 1831493162
Provider Name (Legal Business Name): PATHWAY DIETETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 03/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MACHELLE DR
CARY IL
60013-2399
US

IV. Provider business mailing address

415 MACHELLE DR
CARY IL
60013-2399
US

V. Phone/Fax

Practice location:
  • Phone: 847-354-5584
  • Fax: 888-788-2497
Mailing address:
  • Phone: 847-354-5584
  • Fax: 888-788-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number164.001309
License Number StateIL

VIII. Authorized Official

Name: MS. GAYLE O BOOTH
Title or Position: OWNER/REGISTERED DIETITIAN
Credential: MS RD LDN CDE
Phone: 847-354-5584