Healthcare Provider Details

I. General information

NPI: 1720095961
Provider Name (Legal Business Name): SUSAN MARY BROWN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 W KIRBY AVE
CHAMPAIGN IL
61821-5410
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-384-3490
  • Fax: 217-383-3439
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164003513
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: