Healthcare Provider Details

I. General information

NPI: 1194429316
Provider Name (Legal Business Name): ALISSA FAY BEDTKE LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

6534 N NORTHWEST HWY APT 3C
CHICAGO IL
60631-1448
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-3001
  • Fax:
Mailing address:
  • Phone: 773-401-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.008702
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: