Provider Demographics
NPI:1174327209
Name:WILD TABLE PLLC
Entity type:Organization
Organization Name:WILD TABLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LDN
Authorized Official - Phone:608-438-1612
Mailing Address - Street 1:1842 N ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5073
Mailing Address - Country:US
Mailing Address - Phone:608-438-1612
Mailing Address - Fax:
Practice Address - Street 1:740 N OGDEN AVE APT 4
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7063
Practice Address - Country:US
Practice Address - Phone:608-438-1612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty