Healthcare Provider Details

I. General information

NPI: 1609648187
Provider Name (Legal Business Name): THE FAMILY DIETITIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 WOLF RD STE 135
WESTERN SPRINGS IL
60558-2201
US

IV. Provider business mailing address

5600 WOLF RD STE 135
WESTERN SPRINGS IL
60558-2201
US

V. Phone/Fax

Practice location:
  • Phone: 773-875-5683
  • Fax:
Mailing address:
  • Phone: 773-875-5683
  • Fax: 708-274-1163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: LESLIE VLAZNY STILES
Title or Position: DIETITIAN
Credential: RD
Phone: 773-875-5683