Healthcare Provider Details

I. General information

NPI: 1306615091
Provider Name (Legal Business Name): CLINICA DE NUTRICION DEL SUR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE SEGUNDO BERNIER
COAMO PR
00769
US

IV. Provider business mailing address

PO BOX 83
SANTA ISABEL PR
00757-0083
US

V. Phone/Fax

Practice location:
  • Phone: 787-803-8221
  • Fax:
Mailing address:
  • Phone: 787-226-1176
  • 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: EDWILL BURGOS
Title or Position: LIC
Credential:
Phone: 787-242-6225