Healthcare Provider Details

I. General information

NPI: 1316355019
Provider Name (Legal Business Name): MAYA BACH MPH, RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 E ONTARIO ST APT 4506
CHICAGO IL
60611-4784
US

IV. Provider business mailing address

10 E ONTARIO ST APT 4506
CHICAGO IL
60611-4784
US

V. Phone/Fax

Practice location:
  • Phone: 916-667-2020
  • Fax:
Mailing address:
  • Phone: 916-667-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.006219
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: