Provider Demographics
NPI:1164405577
Name:KLIESCH, MARCI (RD)
Entity Type:Individual
Prefix:MS
First Name:MARCI
Middle Name:
Last Name:KLIESCH
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 1:1 EDGEWATER ST
Mailing Address - Street 2:SUITE 723
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4900
Mailing Address - Country:US
Mailing Address - Phone:718-226-1047
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:1460 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3914
Practice Address - Country:US
Practice Address - Phone:718-442-0300
Practice Address - Fax:781-981-5047
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005339133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ09136Medicare UPIN
NY9226E1Medicare ID - Type Unspecified