Healthcare Provider Details

I. General information

NPI: 1154252286
Provider Name (Legal Business Name): DEEPLY ROOTED NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WEST LAKE STREET PMB #40731
CHICAGO IL
60606
US

IV. Provider business mailing address

201 WEST LAKE STREET PMB #40731
CHICAGO IL
60606
US

V. Phone/Fax

Practice location:
  • Phone: 708-318-7933
  • Fax:
Mailing address:
  • Phone: 708-318-7933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. PAIGE MANSO
Title or Position: OWNER
Credential: MS RD CPT CFNIP LDN
Phone: 708-925-2025