Healthcare Provider Details

I. General information

NPI: 1629169388
Provider Name (Legal Business Name): MARY MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 E BELVIDERE RD PAVILION C STE 385
GRAYSLAKE IL
60030-2012
US

IV. Provider business mailing address

680 N LAKE SHORE DR SUITE 1000
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 847-535-7647
  • Fax: 847-535-7260
Mailing address:
  • Phone: 312-695-9797
  • Fax: 847-535-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164001864
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: