Healthcare Provider Details

I. General information

NPI: 1831001908
Provider Name (Legal Business Name): KYOUNG EUN OH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 W GOLF RD
LIBERTYVILLE IL
60048-3056
US

IV. Provider business mailing address

1128 W GOLF RD
LIBERTYVILLE IL
60048-3056
US

V. Phone/Fax

Practice location:
  • Phone: 847-641-0792
  • Fax:
Mailing address:
  • Phone: 847-641-0792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number814878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: