Healthcare Provider Details

I. General information

NPI: 1174724843
Provider Name (Legal Business Name): JEANNETE RIVERA CRUZ LIC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 11/14/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CASA LINA AVE. #1 SUITE 101 177 ROUTE LOS FILTROS
BAYAMON PR
00969
US

IV. Provider business mailing address

PMB 509 P.O.BOX 7891
GUAYNABO PR
00970-7891
US

V. Phone/Fax

Practice location:
  • Phone: 787-789-1919
  • Fax: 787-789-1921
Mailing address:
  • Phone: 787-789-1919
  • Fax: 787-789-1921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number964
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: