Provider Demographics
NPI:1528822079
Name:DIZGROW PLLC
Entity type:Organization
Organization Name:DIZGROW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:DISBROW
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD LDN
Authorized Official - Phone:309-828-6157
Mailing Address - Street 1:1902 BERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2433
Mailing Address - Country:US
Mailing Address - Phone:309-828-6157
Mailing Address - Fax:309-322-6475
Practice Address - Street 1:322 SUSAN DR STE C1
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6260
Practice Address - Country:US
Practice Address - Phone:701-484-2217
Practice Address - Fax:309-322-6475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty