Healthcare Provider Details

I. General information

NPI: 1306050471
Provider Name (Legal Business Name): LAURA MARIE SEWERYN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 SOUTHWEST HWY LOWER LEVEL
CHICAGO RIDGE IL
60415-1367
US

IV. Provider business mailing address

10943 MAJOR AVE
CHICAGO RIDGE IL
60415-2410
US

V. Phone/Fax

Practice location:
  • Phone: 708-581-7308
  • Fax: 708-581-7309
Mailing address:
  • Phone: 708-422-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164001840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: