Healthcare Provider Details

I. General information

NPI: 1841606035
Provider Name (Legal Business Name): BRET MOYER RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 W FULTON ST
CHICAGO IL
60612-2345
US

IV. Provider business mailing address

17W 718 BUTTERFIELD RD APT 307
OAKBROOK TERRACE IL
60181
US

V. Phone/Fax

Practice location:
  • Phone: 312-850-3438
  • Fax:
Mailing address:
  • Phone: 631-338-8794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1067229
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: