Healthcare Provider Details

I. General information

NPI: 1396920765
Provider Name (Legal Business Name): CARLY N TRUEGER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2008
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N FAIRBANKS CT SUITE 7-121
CHICAGO IL
60611-3013
US

IV. Provider business mailing address

710 N FAIRBANKS CT SUITE 7-121
CHICAGO IL
60611-3013
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-7437
  • Fax:
Mailing address:
  • Phone: 312-926-7437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164004400
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number48006889
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: