Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 4880-12 | WI |
NPI | 1114283157 |
---|---|
Provider Name | Derek M Thiel |
First Address | Oak Brook, IL 60523-1266 |
Second Address | Brookfield, WI 53005-2398 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2012 |
Last Update Date | 28/06/2021 |