Healthcare Provider Details

I. General information

NPI: 1154785442
Provider Name (Legal Business Name): CONWAY NUTRITION SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5328 FAWN CT
OAK FOREST IL
60452-2200
US

IV. Provider business mailing address

5328 FAWN CT
OAK FOREST IL
60452-2200
US

V. Phone/Fax

Practice location:
  • Phone: 708-305-4402
  • Fax: 708-535-2268
Mailing address:
  • Phone: 708-305-4402
  • Fax: 708-535-2268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.001485
License Number StateIL

VIII. Authorized Official

Name: JENNIFER W CONWAY
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 708-305-4402