Healthcare Provider Details

I. General information

NPI: 1013727353
Provider Name (Legal Business Name): IC NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 01/09/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

A3 AVE MIGUEL MELENDEZ MUNOZ
CAYEY PR
00736
US

IV. Provider business mailing address

URB MIRADOR UNIVERSITARIO CALLE 22 B13
CAYEY PR
00736
US

V. Phone/Fax

Practice location:
  • Phone: 787-903-8020
  • Fax:
Mailing address:
  • Phone: 787-616-9858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ILCA JEANNETTE CRUZ SANTIAGO
Title or Position: OWNER
Credential: LND
Phone: 787-616-9858