Healthcare Provider Details

I. General information

NPI: 1902157191
Provider Name (Legal Business Name): SAMANTHA MARY MAREK R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 05/19/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 QUAIL RIDGE DR
WESTMONT IL
60559-6145
US

IV. Provider business mailing address

460 QUAIL RIDGE DR
WESTMONT IL
60559-6145
US

V. Phone/Fax

Practice location:
  • Phone: 630-986-2800
  • Fax:
Mailing address:
  • Phone: 630-986-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.005682
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: