MEDICARE: MARIANNE GRONSTAL CAMPBELL RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1005X	Renal Nutrition Registered Dietitian	334	NE
2	133VN1005X	Renal Nutrition Registered Dietitian	00025	IA

General Provider Information

NPI Number	:	1033279781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANNE GRONSTAL CAMPBELL RD

Provider Business Mailing Address
First Line	:	451 FRANK ST
Second Line	:
City	:	COUNCIL BLUFFS
State	:	IA
Zip	:	51503-4551
Country	:	US
Telephone Number	:	712-322-7605
Fax Number	:

Provider Business Practice Location Address
First Line	:	5084 AMES AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68104-2323
Country	:	US
Telephone Number	:	402-451-7745
Fax Number	:	402-451-8090

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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