MEDICARE: NEDA KHUDEIRA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1006X	Metabolic Nutrition Registered Dietitian	164.007233	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	164.007233	OTHER	IL	LICENSED DIETITAN NUTRITIONIST

General Provider Information

NPI Number	:	1114425618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEDA KHUDEIRA

Provider Business Mailing Address
First Line	:	9405 S OKETO AVE
Second Line	:
City	:	BRIDGEVIEW
State	:	IL
Zip	:	60455-2140
Country	:	US
Telephone Number	:	773-585-0480
Fax Number	:	773-585-0482

Provider Business Practice Location Address
First Line	:	8071 S CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-2003
Country	:	US
Telephone Number	:	773-585-0480
Fax Number	:	773-585-0482

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2018
Last Update Date	:	01/30/2018

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Directions to “ NEDA KHUDEIRA ” Practice Location

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