MEDICARE: CORAL NUTRITION COACH, LLC

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	133VN1004X	Pediatric Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1649865445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORAL NUTRITION COACH, LLC

Provider Business Mailing Address
First Line	:	5415 S DORCHESTER AVE APT BSMT
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-5328
Country	:	US
Telephone Number	:	773-710-2237
Fax Number	:	872-244-3810

Provider Business Practice Location Address
First Line	:	5415 S DORCHESTER AVE APT BSMT
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-5328
Country	:	US
Telephone Number	:	773-710-2237
Fax Number	:	872-244-3810

Authorized Official
Title or Position	:	OWNER AND PROVIDER
Name	:	JESSICA CORAL ALLENDER
Credential	:	MS, RD, LDN
Telephone Number	:	773-710-2237

Provider Enumeration Date	:	03/03/2021
Last Update Date	:	03/03/2021

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