Provider Demographics
NPI:1588845648
Name:REITER, MARY CLARE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CLARE
Last Name:REITER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 HOMAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-9633
Mailing Address - Country:US
Mailing Address - Phone:217-222-1301
Mailing Address - Fax:217-222-1301
Practice Address - Street 1:4505 HOMAN CREEK DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-9633
Practice Address - Country:US
Practice Address - Phone:217-222-1301
Practice Address - Fax:217-222-1301
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164001391133V00000X
MO2004025297133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered