Healthcare Provider Details

I. General information

NPI: 1851778179
Provider Name (Legal Business Name): GABRIELA TIRADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 AVENIDAD PONCE DE LEON NUTRITION DEPT.
SAN JUAN PR
00909-1958
US

IV. Provider business mailing address

1960 CALLE ESPANA URB OCEAN PARK
SAN JUAN PR
00911-2101
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-2000
  • Fax:
Mailing address:
  • Phone: 787-486-6495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number1927
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: