Provider Demographics
NPI:1972746717
Name:BEAL, PAIGE L (RD, LDN)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:L
Last Name:BEAL
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:BROMENN DIABETES SERVICES
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-268-5952
Mailing Address - Fax:309-268-5451
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:BROMENN DIABETES SERVICES
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-268-5952
Practice Address - Fax:309-268-5451
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.000928133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK10652Medicare PIN