Healthcare Provider Details

I. General information

NPI: 1649781725
Provider Name (Legal Business Name): BONITA L MALINOWSKI MS RD CSR LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W COURT ST
KANKAKEE IL
60901-3661
US

IV. Provider business mailing address

455 W COURT ST STE 100
KANKAKEE IL
60901-3692
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-3077
  • Fax: 815-937-8743
Mailing address:
  • Phone: 815-937-3077
  • Fax: 815-937-8743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: