Provider Demographics
NPI:1437491644
Name:INGRAM, THEODIS JR (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:THEODIS
Middle Name:
Last Name:INGRAM
Suffix:JR
Gender:M
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:INGRAM
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:REGISTERED DIETITIAN
Mailing Address - Street 1:6 E MONROE ST
Mailing Address - Street 2:#603
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2704
Mailing Address - Country:US
Mailing Address - Phone:312-208-1233
Mailing Address - Fax:
Practice Address - Street 1:6 E MONROE ST
Practice Address - Street 2:#603
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-2704
Practice Address - Country:US
Practice Address - Phone:312-208-1233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004677133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered