Provider Demographics
NPI:1871867879
Name:BOSCO, MARY M (RD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:BOSCO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-6127
Mailing Address - Fax:208-367-7316
Practice Address - Street 1:3250 W CHERRY LANE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-367-6127
Practice Address - Fax:208-367-7316
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA852745133V00000X
IDD-751133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered