MEDICARE: JACI ELIZABETH LAKE RD

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	133V00000X	Registered Dietitian	164.006872	IL

General Provider Information

NPI Number	:	1235776816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACI ELIZABETH LAKE RD

Provider Business Mailing Address
First Line	:	7843 COOLIDGE RD
Second Line	:
City	:	OAKDALE
State	:	IL
Zip	:	62268-1415
Country	:	US
Telephone Number	:	618-978-3551
Fax Number	:

Provider Business Practice Location Address
First Line	:	432 N PLEASANT AVE
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3006
Country	:	US
Telephone Number	:	618-436-8114
Fax Number	:

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

Provider Enumeration Date	:	12/03/2019
Last Update Date	:	12/03/2019

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