Provider Demographics
NPI:1508913427
Name:TRENTACOSTI, LORI (REGISTERED DIETICIAN)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:TRENTACOSTI
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-549-5128
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-549-5128
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-000649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203887OtherLEGACY
IL7210895OtherAETNA
IL078833OtherHEALTH ALLIANCE
IL3932056OtherBCBS OF IL
IL710000734OtherRR MEDICARE