Basic Information
| Provider Information | |||||||||
| NPI: | 1982012241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEVINE NUTRITION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6661 PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604772849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086120876 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6661 PARKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604772849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086120876 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2014 | ||||||||
| LastUpdateDate: | 07/30/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEVINE RICKERT | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7086120876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MS RD CSSD LDN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 164004722 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.