Healthcare Provider Details

I. General information

NPI: 1891922241
Provider Name (Legal Business Name): MIRIAM YAZMIN PAGAN RIVERA LND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 03/12/2023
Certification Date: 03/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PONCE HEALTH SCIENCES UNIVERSITY INDUSTRIAL REPARADA CALLE 10 G 6
PONCE PR
00716
US

IV. Provider business mailing address

URB.EXT. JARDINES DE COAMO CALLE -10 G-6
COAMO P.R.
00769
UM

V. Phone/Fax

Practice location:
  • Phone: 787-204-0724
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1503
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: