Provider Demographics
NPI:1205440492
Name:REIL, MARIAH (MS, RD, LN)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:REIL
Suffix:
Gender:F
Credentials:MS, RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 N DEVON AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:TEA
Mailing Address - State:SD
Mailing Address - Zip Code:57064-2383
Mailing Address - Country:US
Mailing Address - Phone:605-214-1795
Mailing Address - Fax:
Practice Address - Street 1:4800 W 57TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2239
Practice Address - Country:US
Practice Address - Phone:605-214-1795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0731133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86132732OtherCDR RD REGISTRATION NUMBER
SD0731OtherLICENSED NUTRITIONIST