| Doctor Name: | MRS. ELLEN ROTH |
| NPI Number: | 1396141859 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | R.D. |
| License Number: | 164000669 |
| Business Practice Address: | 9 Heartland Dr Ste C Bloomington, IL - 617047733 |
| Business Phone Number: | 3096637643 |
| Business Fax Number: | 3096638359 |
| Mailing Address: | 9 Heartland Dr Ste C, BLOOMINGTON |
| State: | IL |
| Postal Code: | 617047733 |
| Phone Number: | 3096637643 |
| Fax Number: | 3096638359 |
| NPI Enumeration Date: | 11/11/2014 |
| NPI Last Update Date: | 11/11/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 133V00000X |
| License Number: | 164000669 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Dietary & Nutritional Service Providers |
| Taxonomy Classification: | Dietitian, Registered |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A registered dietician (RD) is a food and nutrition expert who has successfully completed a minimum of a bachelor |