Provider Demographics
NPI:1831493162
Name:PATHWAY DIETETICS LLC
Entity Type:Organization
Organization Name:PATHWAY DIETETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:O
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD LDN CDE
Authorized Official - Phone:847-354-5584
Mailing Address - Street 1:415 MACHELLE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-2399
Mailing Address - Country:US
Mailing Address - Phone:847-354-5584
Mailing Address - Fax:888-788-2497
Practice Address - Street 1:415 MACHELLE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-2399
Practice Address - Country:US
Practice Address - Phone:847-354-5584
Practice Address - Fax:888-788-2497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2015-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001309261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL164.001309OtherSTATE OF IL DIVISION OF PROFESSIONAL REGULATION
IL164.001309OtherSTATE OF IL DIVISION OF PROFESSIONAL REGULATION
1851618615Medicare PIN