Provider Demographics
NPI:1275006074
Name:CHIU, SUREN JENNY (LDN)
Entity Type:Individual
Prefix:
First Name:SUREN
Middle Name:JENNY
Last Name:CHIU
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:SUREN
Other - Middle Name:
Other - Last Name:KANCHANAVALEERAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4775 E MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-8802
Mailing Address - Country:US
Mailing Address - Phone:217-864-3737
Mailing Address - Fax:217-864-3468
Practice Address - Street 1:4775 E MARYLAND ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-8802
Practice Address - Country:US
Practice Address - Phone:217-876-3737
Practice Address - Fax:217-876-3468
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007568133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist