Healthcare Provider Details

I. General information

NPI: 1487085791
Provider Name (Legal Business Name): ILLINOIS DIETITIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 LAKE ST. , SUITE 220
OAK PARK IL
60301-1411
US

IV. Provider business mailing address

PO BOX 4004
OAK PARK IL
60303-4004
US

V. Phone/Fax

Practice location:
  • Phone: 708-285-1347
  • Fax: 708-356-6611
Mailing address:
  • Phone: 708-285-1347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.004823
License Number StateIL

VIII. Authorized Official

Name: MS. EILEEN H MCCARTHY
Title or Position: OWNER, RD
Credential: RD
Phone: 708-285-1347