Provider Demographics
NPI:1568062404
Name:LEWIS, MATHABENG KHEKO (MS, RD)
Entity Type:Individual
Prefix:
First Name:MATHABENG
Middle Name:KHEKO
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 CHRISMAN DR
Mailing Address - Street 2:
Mailing Address - City:STREAMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60107-6869
Mailing Address - Country:US
Mailing Address - Phone:708-244-7947
Mailing Address - Fax:
Practice Address - Street 1:225 W HUBBARD ST STE 302
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4916
Practice Address - Country:US
Practice Address - Phone:312-216-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007970133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered