Healthcare Provider Details

I. General information

NPI: 1114425618
Provider Name (Legal Business Name): NEDA KHUDEIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8071 S CICERO AVE
CHICAGO IL
60652-2003
US

IV. Provider business mailing address

9405 S OKETO AVE
BRIDGEVIEW IL
60455-2140
US

V. Phone/Fax

Practice location:
  • Phone: 773-585-0480
  • Fax: 773-585-0482
Mailing address:
  • Phone: 773-585-0480
  • Fax: 773-585-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164.007233
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: