Healthcare Provider Details

I. General information

NPI: 1811227549
Provider Name (Legal Business Name): MEGAN ELIZABETH MOON RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN ELIZABETH SMIDDY RD LDN

II. Dates (important events)

Enumeration Date: 12/31/2009
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 VERMONT ST
QUINCY IL
62301-3119
US

IV. Provider business mailing address

1040 1/2 BROADWAY ST
QUINCY IL
62301-2835
US

V. Phone/Fax

Practice location:
  • Phone: 217-223-8400
  • Fax: 217-223-9716
Mailing address:
  • Phone: 217-223-8400
  • Fax: 217-223-9716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number164005000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: