Basic Information
| Provider Information | |||||||||
| NPI: | 1568676617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTEMPA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10035 S CLIFTON PARK AVE | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608053408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084226200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084226200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1640000557 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.