Healthcare Provider Details

I. General information

NPI: 1346882412
Provider Name (Legal Business Name): MORGAN M WIGGS RD, LDN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N PROMENADE ST
HAVANA IL
62644-1243
US

IV. Provider business mailing address

615 N PROMENADE ST
HAVANA IL
62644-1243
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-4431
  • Fax:
Mailing address:
  • Phone: 309-543-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164007848
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: