Provider Demographics
NPI:1194818732
Name:BLANK, SCOTT (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BLANK
Suffix:
Gender:M
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 NORTH KNOXVILLE AVE.
Mailing Address - Street 2:PROCTOR HOSPITAL
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-1056
Mailing Address - Fax:309-689-6010
Practice Address - Street 1:5409 NORTH KNOXVILLE AVE.
Practice Address - Street 2:PROCTOR HOSPITAL
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-691-1056
Practice Address - Fax:309-689-6010
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
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
ILK05009Medicare UPIN