Basic Information
| Provider Information | |||||||||
| NPI: | 1871246470 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7712 SOLUTION CENTER | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606770001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129961000 | ||||||||
| FaxNumber: | 3129961001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 W TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606127232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967699 | ||||||||
| FaxNumber: | 3129961001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2022 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZENN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3129963620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS | ||||||||
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| NPICertificationDate: | 01/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.