Healthcare Provider Details

I. General information

NPI: 1275887317
Provider Name (Legal Business Name): MORAIMA GARCIA VERGARA LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 CALLE VICTORIA STE 17 LEGACY MEDICAL CENTER
HUMACAO PR
00791-4494
US

IV. Provider business mailing address

104 CALLE LUIS MUNOZ RIVERA
YABUCOA PR
00767-3103
US

V. Phone/Fax

Practice location:
  • Phone: 787-318-2041
  • Fax:
Mailing address:
  • Phone: 787-266-0907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1666
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: