Healthcare Provider Details

I. General information

NPI: 1003825167
Provider Name (Legal Business Name): MAYRA E MONTES RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAYRA ENID MONTES GONZALEZ

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 SANTA CRUZ ST 4TH FLOOR
BAYAMON PR
00959
US

IV. Provider business mailing address

H3 MEADOWS TOWER APT 10B SAN PATRICIO AVE
GUAYNABO PR
00968-3286
US

V. Phone/Fax

Practice location:
  • Phone: 787-740-6722
  • Fax:
Mailing address:
  • Phone: 787-365-4298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR495985
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number627
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: