Healthcare Provider Details

I. General information

NPI: 1780028514
Provider Name (Legal Business Name): NUTRIDYNAMIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N NORTH CT SUITE 270
PALATINE IL
60067-8157
US

IV. Provider business mailing address

951 OLD CHECKER RD
BUFFALO GROVE IL
60089-1647
US

V. Phone/Fax

Practice location:
  • Phone: 847-701-8345
  • Fax:
Mailing address:
  • Phone: 847-772-3844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE SWAGEL
Title or Position: OWNER/MEMBER
Credential: RDN, LDN
Phone: 847-772-3844