Provider Demographics
NPI:1699312868
Name:RASKY, BENJAMIN MICHAEL (LDN)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:RASKY
Suffix:
Gender:M
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7047 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1015
Mailing Address - Country:US
Mailing Address - Phone:773-303-7505
Mailing Address - Fax:
Practice Address - Street 1:7047 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1015
Practice Address - Country:US
Practice Address - Phone:773-303-7505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007889133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist