MEDICARE: MARIO VILLALOBOS MEDRAN MS, RDN, LDN

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	164008364	IL

General Provider Information

NPI Number	:	1639753908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO VILLALOBOS MEDRAN MS, RDN, LDN

Provider Business Mailing Address
First Line	:	945 N RIDGEWAY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3838
Country	:	US
Telephone Number	:	913-263-4824
Fax Number	:

Provider Business Practice Location Address
First Line	:	1943 S MAY ST # 1F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3359
Country	:	US
Telephone Number	:	312-549-8866
Fax Number	:

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

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	05/12/2021

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