Provider Demographics
NPI:1548512221
Name:SANDERS, RYAN T (RD, LDN)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:T
Last Name:SANDERS
Suffix:
Gender:M
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 OAK GROVE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1631
Mailing Address - Country:US
Mailing Address - Phone:847-903-1394
Mailing Address - Fax:
Practice Address - Street 1:800 N WESTMORELAND RD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1687
Practice Address - Country:US
Practice Address - Phone:847-535-7647
Practice Address - Fax:847-535-8109
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005190133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHZ885ZMedicare PIN