Provider Demographics
NPI:1578011854
Name:KORDELL, GREGORY (CD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:KORDELL
Suffix:
Gender:M
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2661 COUNTY HWY I
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5407
Mailing Address - Country:US
Mailing Address - Phone:715-723-1811
Mailing Address - Fax:
Practice Address - Street 1:2661 COUNTY HIGHWAY I
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-5407
Practice Address - Country:US
Practice Address - Phone:715-723-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2455-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered