Healthcare Provider Details

I. General information

NPI: 1215282868
Provider Name (Legal Business Name): AVELLINO GROUP LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 N HALSTED ST STE 202
CHICAGO IL
60642-2612
US

IV. Provider business mailing address

6400 INDUSTRIAL LOOP
GREENDALE WI
53129-2452
US

V. Phone/Fax

Practice location:
  • Phone: 312-533-7500
  • Fax: 312-778-5993
Mailing address:
  • Phone: 414-423-4100
  • Fax: 414-423-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164003355
License Number StateIL

VIII. Authorized Official

Name: CARLA R HEISER
Title or Position: PRESIDENT
Credential: MS, RD, LD
Phone: 312-533-7500