Provider Demographics
NPI:1992061998
Name:RANGDAL, MAYURI (MS, RD, LDN)
Entity type:Individual
Prefix:MISS
First Name:MAYURI
Middle Name:
Last Name:RANGDAL
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 WEST STONEHENGE CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615
Mailing Address - Country:US
Mailing Address - Phone:309-222-2456
Mailing Address - Fax:
Practice Address - Street 1:2640 W STONEHENGE CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7477
Practice Address - Country:US
Practice Address - Phone:309-222-2456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005407133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered