Healthcare Provider Details

I. General information

NPI: 1124299987
Provider Name (Legal Business Name): AMY BETH CASPER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W IRVING PARK RD FOOD AND NUTRITION SERVICES
CHICAGO IL
60613-3077
US

IV. Provider business mailing address

850 W IRVING PARK RD FOOD AND NUTRITION SERVICES
CHICAGO IL
60613-3077
US

V. Phone/Fax

Practice location:
  • Phone: 773-975-6807
  • Fax: 773-975-6767
Mailing address:
  • Phone: 773-975-6807
  • Fax: 773-975-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.004027
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: