Provider Demographics
NPI:1073579991
Name:MAGER, LORI D (RD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:D
Last Name:MAGER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:D
Other - Last Name:BAKKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 SYRACUSE LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-3319
Mailing Address - Country:US
Mailing Address - Phone:847-895-8038
Mailing Address - Fax:
Practice Address - Street 1:77 N AIRLITE ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4912
Practice Address - Country:US
Practice Address - Phone:847-888-5461
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04844Medicare ID - Type Unspecified