Provider Demographics
NPI:1487085791
Name:ILLINOIS DIETITIANS, LLC
Entity type:Organization
Organization Name:ILLINOIS DIETITIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, RD
Authorized Official - Prefix:MS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:708-285-1347
Mailing Address - Street 1:PO BOX 4004
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-4004
Mailing Address - Country:US
Mailing Address - Phone:708-285-1347
Mailing Address - Fax:
Practice Address - Street 1:715 LAKE ST. , SUITE 220
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1411
Practice Address - Country:US
Practice Address - Phone:708-285-1347
Practice Address - Fax:708-356-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004823133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty