Healthcare Provider Details

I. General information

NPI: 1699168211
Provider Name (Legal Business Name): RIVER NORTH NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 E ONTARIO ST UNIT 4506
CHICAGO IL
60611-2736
US

IV. Provider business mailing address

10 E ONTARIO ST UNIT 4506
CHICAGO IL
60611-2736
US

V. Phone/Fax

Practice location:
  • Phone: 872-225-0838
  • Fax:
Mailing address:
  • Phone: 872-225-0838
  • 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: MAYA FRIEDMAN
Title or Position: OWNER
Credential: MPH, RD, LDN
Phone: 916-667-2020