Provider Demographics
NPI:1154875516
Name:BALBOA, PEGGY (RD)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:BALBOA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 S DRYDEN PL
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2137
Mailing Address - Country:US
Mailing Address - Phone:847-830-0098
Mailing Address - Fax:
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:SUITE A-4600
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-7400
Practice Address - Fax:773-564-7401
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005248133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered