Healthcare Provider Details

I. General information

NPI: 1922480342
Provider Name (Legal Business Name): HEATHER MASTERS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 DAKOTA ST STE A
CRYSTAL LAKE IL
60012
US

IV. Provider business mailing address

650 DAKOTA ST STE A
CRYSTAL LAKE IL
60012-3744
US

V. Phone/Fax

Practice location:
  • Phone: 815-338-6600
  • Fax: 815-356-1104
Mailing address:
  • Phone: 815-338-6600
  • Fax: 815-356-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164006477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: