Healthcare Provider Details

I. General information

NPI: 1376157479
Provider Name (Legal Business Name): ADRIANA BUENO NDTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE # 59
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

4220 S CHAMPLAIN AVE APT 2N
CHICAGO IL
60653-2951
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-1210
  • Fax:
Mailing address:
  • Phone: 815-545-7317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86052267
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: