Healthcare Provider Details

I. General information

NPI: 1043696289
Provider Name (Legal Business Name): CRISTAL GONZALEZ ESTREMERA LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 URB CATALANA
BARCELONETA PR
00617-2725
US

IV. Provider business mailing address

PO BOX 2020 PMB 288
BARCELONETA PR
00617-2020
US

V. Phone/Fax

Practice location:
  • Phone: 787-462-9480
  • Fax:
Mailing address:
  • Phone: 787-462-9480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1934
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: