Provider Demographics
NPI:1164647004
Name:MAGLIOLA, MARTHA LEAH (RD,CD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LEAH
Last Name:MAGLIOLA
Suffix:
Gender:F
Credentials:RD,CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14650 TRANQUIL CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8301
Mailing Address - Country:US
Mailing Address - Phone:574-277-5378
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000920A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941030WWMedicare ID - Type Unspecified