Provider Demographics
NPI:1801062633
Name:BUMBACO, LORI (MS, RDN, CSO, LDN)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BUMBACO
Suffix:
Gender:F
Credentials:MS, RDN, CSO, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ONWENTSIA AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2030
Mailing Address - Country:US
Mailing Address - Phone:201-787-2220
Mailing Address - Fax:
Practice Address - Street 1:610 ONWENTSIA AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2030
Practice Address - Country:US
Practice Address - Phone:201-787-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL943720133VN1006X
133VN1301X
IL164.006161133VN1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic