Healthcare Provider Details

I. General information

NPI: 1972622512
Provider Name (Legal Business Name): KRISTINA D ADAMS SMITH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 HEALTH CENTER DRIVE SUITE 101
MATTOON IL
61938
US

IV. Provider business mailing address

1005 HEALTH CENTER DRIVE SUITE 101
MATTOON IL
61938
US

V. Phone/Fax

Practice location:
  • Phone: 217-238-4774
  • Fax: 217-238-4775
Mailing address:
  • Phone: 217-238-4774
  • Fax: 217-238-4775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.003450
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: