Healthcare Provider Details

I. General information

NPI: 1265026769
Provider Name (Legal Business Name): NUTRIVATE, CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33-5 CALLE 11
CAROLINA PR
00985-5436
US

IV. Provider business mailing address

L8 CALLE MONTE MEMBRILLO
CAROLINA PR
00987-8023
US

V. Phone/Fax

Practice location:
  • Phone: 787-225-6040
  • Fax:
Mailing address:
  • Phone: 787-220-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: SONIA Y CRUZ
Title or Position: NUTRITIONIST/DIETITIAN
Credential:
Phone: 787-220-9051