Healthcare Provider Details

I. General information

NPI: 1821455205
Provider Name (Legal Business Name): EDLIN MARTINEZ LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE DE DIEGO E
MAYAGUEZ PR
00680-4866
US

IV. Provider business mailing address

PO BOX 276
SAN SEBASTIAN PR
00685-0276
US

V. Phone/Fax

Practice location:
  • Phone: 787-265-3320
  • Fax: 787-265-2929
Mailing address:
  • Phone: 787-422-2380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1938
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: