Healthcare Provider Details

I. General information

NPI: 1649861212
Provider Name (Legal Business Name): NUTRIVATE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROBERTO CLEMENTE AVENUE 33-5
CAROLINA PR
00985
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: MRS. SONIA Y CRUZ
Title or Position: NUTRITIONIST/DIETITIAN
Credential: LND
Phone: 787-220-9051