MEDICARE: BELOVED COMMUNITY FAMILY WELLNESS CTR

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	136A00000X	Registered Dietetic Technician	86034476	IL

General Provider Information

NPI Number	:	1891123832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELOVED COMMUNITY FAMILY WELLNESS CTR

Provider Business Mailing Address
First Line	:	6821 S HALSTED STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621
Country	:	US
Telephone Number	:	773-651-3629
Fax Number	:	773-322-1599

Provider Business Practice Location Address
First Line	:	6821 S HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-1833
Country	:	US
Telephone Number	:	773-651-3629
Fax Number	:	773-322-1599

Authorized Official
Title or Position	:	DIETICIAN
Name	:	MS. ASSENATH NAAMAN
Credential	:	LDN
Telephone Number	:	773-651-3629

Provider Enumeration Date	:	10/30/2013
Last Update Date	:	10/30/2013

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