Healthcare Provider Details

I. General information

NPI: 1952002347
Provider Name (Legal Business Name): DIETITIAN SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 RIVER RD N STE 103
KEIZER OR
97303-5994
US

IV. Provider business mailing address

3581 PERSIMMON DR
ALGONQUIN IL
60102-4816
US

V. Phone/Fax

Practice location:
  • Phone: 224-623-3330
  • Fax:
Mailing address:
  • Phone: 224-623-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ASHLEIGH STARR
Title or Position: REGISTERED DIETITIAN
Credential: RDN
Phone: 224-623-3330