Healthcare Provider Details

I. General information

NPI: 1649865445
Provider Name (Legal Business Name): CORAL NUTRITION COACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 S DORCHESTER AVE APT BSMT
CHICAGO IL
60615-5328
US

IV. Provider business mailing address

5415 S DORCHESTER AVE APT BSMT
CHICAGO IL
60615-5328
US

V. Phone/Fax

Practice location:
  • Phone: 773-710-2237
  • Fax: 872-244-3810
Mailing address:
  • Phone: 773-710-2237
  • Fax: 872-244-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JESSICA CORAL ALLENDER
Title or Position: OWNER AND PROVIDER
Credential: MS, RD, LDN
Phone: 773-710-2237