Healthcare Provider Details

I. General information

NPI: 1477673283
Provider Name (Legal Business Name): MRS. MARIBEL COLLAZO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE SERGIO CUEVAS BUSTAMANTE 550
HATO REY PR
00918
US

IV. Provider business mailing address

473 CALLE BAYAMON LA CUMBRE
SAN JUAN PR
00926-5558
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-8383
  • Fax:
Mailing address:
  • Phone: 787-922-7053
  • Fax: 787-703-1646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1298
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: