Healthcare Provider Details

I. General information

NPI: 1588487136
Provider Name (Legal Business Name): LILLIAN SIERRA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 RIO DORADO DR
LA MESA NM
88044-9655
US

IV. Provider business mailing address

6505 RIO DORADO DR
LA MESA NM
88044-9655
US

V. Phone/Fax

Practice location:
  • Phone: 915-204-3335
  • Fax:
Mailing address:
  • Phone: 915-204-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT85848
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: