Healthcare Provider Details

I. General information

NPI: 1053123059
Provider Name (Legal Business Name): CARMEN M NEVAREZ LND MHSN IOC SPORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2025
Last Update Date: 01/25/2025
Certification Date: 01/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARACAIBO B68 PARK GARDENS SAN JUAN
SAN JUAN, PR PR
00926-2245
US

IV. Provider business mailing address

MARACAIBO B68 PARK GARDENS
SAN JUAN PR
00926-2245
US

V. Phone/Fax

Practice location:
  • Phone: 787-486-8181
  • Fax:
Mailing address:
  • Phone: 787-486-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number716
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number716
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: