Healthcare Provider Details

I. General information

NPI: 1285010363
Provider Name (Legal Business Name): TARA ALLEN MS, RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 W 203RD ST STE 310
OLYMPIA FLDS IL
60461-1182
US

IV. Provider business mailing address

35318 EAGLE WAY
CHICAGO IL
60678-1353
US

V. Phone/Fax

Practice location:
  • Phone: 708-679-2130
  • Fax: 708-679-2260
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.006439
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: