Provider Demographics
NPI:1548794704
Name:SOBOTKA, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SOBOTKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5606
Mailing Address - Country:US
Mailing Address - Phone:312-627-0444
Mailing Address - Fax:312-648-0155
Practice Address - Street 1:619 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-5606
Practice Address - Country:US
Practice Address - Phone:312-627-0444
Practice Address - Fax:312-648-0155
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI164007047133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered