Healthcare Provider Details

I. General information

NPI: 1891121505
Provider Name (Legal Business Name): NORA KOCH RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD RM 110
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

5000 S 5TH AVE
HINES IL
60141-3030
US

V. Phone/Fax

Practice location:
  • Phone: 224-610-5407
  • Fax:
Mailing address:
  • Phone: 708-202-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164006001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: