Provider Demographics
NPI:1720142078
Name:GRIEB, MARY LEE (RD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LEE
Last Name:GRIEB
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 SOUTH LAFOUNTAIN STREET
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-9011
Mailing Address - Country:US
Mailing Address - Phone:765-453-8352
Mailing Address - Fax:765-453-8457
Practice Address - Street 1:3500 SOUTH LAFOUNTAIN STREET
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46904-9011
Practice Address - Country:US
Practice Address - Phone:765-453-8352
Practice Address - Fax:765-453-8457
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000174A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN213690Medicare NSC