Provider Demographics
NPI:1154785442
Name:CONWAY NUTRITION SERVICES, INC.
Entity type:Organization
Organization Name:CONWAY NUTRITION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:W
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-305-4402
Mailing Address - Street 1:5328 FAWN CT
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2200
Mailing Address - Country:US
Mailing Address - Phone:708-305-4402
Mailing Address - Fax:708-535-2268
Practice Address - Street 1:5328 FAWN CT
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2200
Practice Address - Country:US
Practice Address - Phone:708-305-4402
Practice Address - Fax:708-535-2268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.001485133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty