Individual provider · NPI-1

James Kevin Gilligan Jr., RD, LD

Dietitian, Registered · Mattoon, IL

NPI number1629453097
StatusActive
Last updated in NPPESJul 27, 2015

Details

NPI
1629453097
Entity type
Individual (NPI-1)
Name
Mr. James Kevin Gilligan Jr.
Credential
RD, LD
Sex
Male
Sole proprietor
No
Enumeration date
Jul 27, 2015
Last updated
Jul 27, 2015

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
133V00000X Dietitian, Registered164006502ILYes
133V00000X Dietitian, Registered2012036779MO

Practice location

501 Lake Land Blvd
Mattoon, IL 61938-5283

Phone 217-258-3370

Mailing address

6612 Winnebago St
Saint Louis, MO 63109-1245

Phone 314-537-0932

Is something wrong?

This page shows exactly what the provider filed with NPPES. Only the provider (or their surrogate) can change it, by signing in to NPPES. Our page updates within a day of their change. See how to update NPI information.

Other Dietitian, Registered providers in Mattoon, IL