Provider Demographics
NPI:1285670729
Name:GROSVENOR, MARY B (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:GROSVENOR
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:PO BOX 10100
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-0008
Mailing Address - Country:US
Mailing Address - Phone:970-874-2470
Mailing Address - Fax:
Practice Address - Street 1:1501 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2815
Practice Address - Country:US
Practice Address - Phone:970-874-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO637966133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840428757037OtherROCKY MOUNTAIN HEALTH PLA
CO840428757016OtherROCKY MOUNTAIN HEALTH PLA
COGR675759OtherBCBS
COC802949Medicare PIN
CO840428757037OtherROCKY MOUNTAIN HEALTH PLA