Healthcare Provider Details

I. General information

NPI: 1730537267
Provider Name (Legal Business Name): CUPP NUTRITION SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 SPRUCE RD
FRANKFORT IL
60423-1039
US

IV. Provider business mailing address

733 SPRUCE RD
FRANKFORT IL
60423-1039
US

V. Phone/Fax

Practice location:
  • Phone: 815-263-4402
  • Fax: 815-464-9734
Mailing address:
  • Phone: 815-263-4402
  • Fax: 815-464-9734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.000250
License Number StateIL

VIII. Authorized Official

Name: MARLENE CUPP
Title or Position: DIETITAN
Credential: RD, LDN
Phone: 815-464-9734