Healthcare Provider Details

I. General information

NPI: 1174443600
Provider Name (Legal Business Name): MOG NUTRICION CLINICA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4NN4 VIA GEORGINA
CAROLINA PR
00983-4746
US

IV. Provider business mailing address

22 CALLE FLORIDIANO APT 2205
CAROLINA PR
00987-7708
US

V. Phone/Fax

Practice location:
  • Phone: 787-603-9706
  • Fax:
Mailing address:
  • Phone: 787-603-9706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MARIELY OLIVERO
Title or Position: NUTRITIONIST
Credential: MHSCN, LND
Phone: 787-307-0844