Healthcare Provider Details

I. General information

NPI: 1942378393
Provider Name (Legal Business Name): VIVIAN W BURR RD MNT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 55TH ST
CHICAGO IL
60615-4906
US

IV. Provider business mailing address

800 E. 55TH STREET
CHICAGO IL
60615
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-0660
  • Fax:
Mailing address:
  • Phone: 773-702-0660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: