Provider Demographics
NPI:1750465084
Name:CICHOWICZ, WAYNE RICHARD (DN, LDN)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:RICHARD
Last Name:CICHOWICZ
Suffix:
Gender:M
Credentials:DN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 S 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-4146
Mailing Address - Country:US
Mailing Address - Phone:708-656-7000
Mailing Address - Fax:
Practice Address - Street 1:3602 S 61ST AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-4146
Practice Address - Country:US
Practice Address - Phone:708-656-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered174400000XOther Service ProvidersSpecialist