Healthcare Provider Details

I. General information

NPI: 1497335335
Provider Name (Legal Business Name): JEREMY GRICAR RDN, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 WOODS LN
HEBRON IL
60034-9515
US

IV. Provider business mailing address

9701 WOODS LN
HEBRON IL
60034-9515
US

V. Phone/Fax

Practice location:
  • Phone: 815-861-5127
  • Fax:
Mailing address:
  • Phone: 815-861-5127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164008331
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: