Healthcare Provider Details

I. General information

NPI: 1528446416
Provider Name (Legal Business Name): DONNA MATT RD, LDN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 JOHN DEERE RD STE 304
MOLINE IL
61265-6812
US

IV. Provider business mailing address

PO BOX 472
VIOLA IL
61486-0472
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-5260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.000880
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: