Provider Demographics
NPI:1093085888
Name:ROCHE DIETITIANS
Entity Type:Organization
Organization Name:ROCHE DIETITIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHE-DUDEK
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD LD FADA CDE
Authorized Official - Phone:708-442-0123
Mailing Address - Street 1:51 E BURLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2124
Mailing Address - Country:US
Mailing Address - Phone:708-442-0123
Mailing Address - Fax:708-442-0930
Practice Address - Street 1:51 E BURLINGTON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2124
Practice Address - Country:US
Practice Address - Phone:708-442-0123
Practice Address - Fax:708-442-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.000278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty