Healthcare Provider Details

I. General information

NPI: 1063918555
Provider Name (Legal Business Name): BRENDA BEBEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 111TH ST
CHICAGO IL
60628-4200
US

IV. Provider business mailing address

5330 FOREST TRL
OAK FOREST IL
60452-4400
US

V. Phone/Fax

Practice location:
  • Phone: 773-995-3234
  • Fax:
Mailing address:
  • Phone: 630-768-4942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: