Healthcare Provider Details

I. General information

NPI: 1073847539
Provider Name (Legal Business Name): LUZ ADRIANA SANCEN DE BROWN RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LUZ BROWN RD, LDN

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 ELM ST
QUINCY IL
62301-3233
US

IV. Provider business mailing address

2009 ELM ST
QUINCY IL
62301-3233
US

V. Phone/Fax

Practice location:
  • Phone: 217-228-0828
  • Fax:
Mailing address:
  • Phone: 217-228-0828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164.005141
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: