Healthcare Provider Details

I. General information

NPI: 1194526210
Provider Name (Legal Business Name): DOUGLAS CORT DRENCKPOHL DCN, RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637
US

IV. Provider business mailing address

1112 N. UNDERHILL
PEORIA IL
61606
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-0621
  • Fax: 309-624-4291
Mailing address:
  • Phone: 309-253-7826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number164002914
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: