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General NPI Number Information
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NPI Number | 1740142256
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Entity Type | Organization
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Legal Business Name | DIETITIAN PRACTICE PLLC
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Dates
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Enumeration Date | 12/02/2025
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Last Update Date | 12/02/2025
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Provider Practice Location Address
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Address Line | 1000 ESSINGTON RD FL 1
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City | JOLIET
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State | IL
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Zip | 60435-2841
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Country | US
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Telephone | 847-769-3393
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Fax |
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Provider Business Mailing Address
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Address Line | 34W038 COUNTRY CLUB RD
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City | ST CHARLES
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State | IL
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Zip | 60174-1471
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Country | US
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Telephone | 847-769-3393
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. KYLE RUSS
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Credential | LDN, CNS
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Telephone | 847-769-3393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174H00000X
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Taxonomy Name | Health Educator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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