Provider Demographics
NPI:1902910789
Name:BANGE, ADAM MICHAEL (RD)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:MICHAEL
Last Name:BANGE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 E 1700TH RD
Mailing Address - Street 2:
Mailing Address - City:BROCTON
Mailing Address - State:IL
Mailing Address - Zip Code:61917-8055
Mailing Address - Country:US
Mailing Address - Phone:217-385-2406
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:NUTRITION AND FOOD SERVICE (120)
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-554-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered