Basic Information
| Provider Information | |||||||||
| NPI: | 1093916611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35318 EAGLE WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606780353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 761 45TH STREET | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199223020 | ||||||||
| FaxNumber: | 2199223023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 926769 | 01 | ADA REGISTRATION NUMBER | OTHER |