Healthcare Provider Details

I. General information

NPI: 1376886820
Provider Name (Legal Business Name): NUTRIMEDICOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 W 18TH ST
CHICAGO IL
60608-4833
US

IV. Provider business mailing address

1719 W 18TH ST
CHICAGO IL
60608-4833
US

V. Phone/Fax

Practice location:
  • Phone: 312-929-2927
  • Fax:
Mailing address:
  • Phone: 312-929-2927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number036117092
License Number StateIL

VIII. Authorized Official

Name: MR. LARRY JENKINS
Title or Position: BILLING MANAGER
Credential:
Phone: 312-953-0547