Provider Demographics
NPI:1881764538
Name:MCCLAIN, CALLI JO (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:CALLI
Middle Name:JO
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6158 S OAKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:POLO
Mailing Address - State:IL
Mailing Address - Zip Code:61064-9013
Mailing Address - Country:US
Mailing Address - Phone:815-946-3111
Mailing Address - Fax:815-599-6103
Practice Address - Street 1:1045 W STEPHENSON ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4864
Practice Address - Country:US
Practice Address - Phone:815-599-6253
Practice Address - Fax:815-599-6103
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK10344Medicare PIN