Healthcare Provider Details

I. General information

NPI: 1972117661
Provider Name (Legal Business Name): JOSE LUIS GUZMAN JR. RDN, LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE # 5906
ALBUQUERQUE NM
87110-7845
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE # 5906
ALBUQUERQUE NM
87110-7845
US

V. Phone/Fax

Practice location:
  • Phone: 815-603-3305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-1318
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: